King Insurance Services

Agency Name:

Phone:

Agency Contact:

Fax:

E-mail Address:

Applicant Business:

Address:

City:

State:

Zip:

Coverage Limit Requested:

Effective Date:

Check Underlying Coverages:

Auto General Liability
Workers Comp Hired and Non Owned Only

General Liability Premium:

General Liability Class:

Number of Autos:

Workers' Comp. Premium:

Description Of Operations:

Annual Sales:

Annual Payroll:

All underlying policies are on occurrence forms?

Yes No

Are all policies rated A-V or higher by A.M. Best?

Yes No

Any losses in the past three years for coverages being provided?

Yes No

Does fleet exceed 10 Extra Heavy Trucks or 25 total vehicles?

Yes No

Notes

Commercial Umbrella-Excess Indication - AIG - Starstone