ASSE Commercial General Liability Insurance
(Application follows)

The coverage for which you are applying is an Annual policy. It is written on a "Per Occurrence" basis - i.e., it responds to claims arising from occurrences which take place during the policy period - regardless of when the claim is made.
If you wish to bind this coverage and your expiring General Liability policy was written on a "Claims Made" basis, you will need to contact that broker to find out what your options may be with regard to "tail" coverage for that policy. (Please note there is usually only a short time frame during which this "tail" coverage is available for purchase when the policy is expiring.)
The application attached becomes a part of your ASSE General Liability policy. Unless otherwise noted or advised, coverage under the policy extends only to the activities you list (unless changed by endorsement) - so it is very important you accurately and completely describe the work to be covered by this policy.
The ASSE General Liability policy excludes professional services – an essential part of your insurance coverage. Therefore, in order to bind any ASSE General Liability coverage, Underwriters require you also maintain the ASSE Professional Liability insurance in equal or greater limits. If you need information on the ASSE Professional Liability Insurance, please give our office a call.
It is preferable any subcontractors you use maintain their own professional and general liability insurance in limits at least equaling yours and name you as an additional insured under their policy. We do have an Additional Insured Form available which may be used to request additional insured status for your clients or subcontractors. That coverage is provided only to the extent that liability arises out of your conduct as the Named Insured.
Watch the wording of your client's contracts! The ASSE General Liability policy provides coverage only with respect to your work and to the extent the same liability would exist in the absence of a contract. It does not cover contractual indemnification requirements nor cover you for failure to maintain a client's insurance requirements. For this reason, it is especially important for you and/or your attorneys to review the contractual and indemnification section of your clients contracts to make sure you are aware of the liabilities you may be assuming and request changes as necessary.
This insurance policy provides only General Liability coverage. Thus for example, the General Liability policy will not provide coverage for the following:
                                    *Automobile Liability (Owned, Non-owned or Hired)
                                    *Workers Compensation
                                    *Employers Liability
                                    *Stop Gap Coverage
                                    *Professional Liability
                                    *Your Personal Business Property
Some of these coverages may be available to us through other markets in certain states. If you are in need of them, let us know. In closing, we are looking forward to working with you. If you have any questions about the application or the coverage, please feel free to give us a call.
issued to
(This is an application for annual “per occurrence” coverage)

A) Please answer all questions in ink, leaving no blank spaces.
B) The application must be signed and dated.
C) When answering questions, please use a separate sheet of paper if space provided is insufficient.
(c) Applicant is:
(e) Any operations sold, acquired, or discontinued in the last five years?
(f) Number of employees:
(g) Financial information:
 Gross IncomeStaff PayrollSubcontractor Payroll*
Past twelve months:
Estimate of next twelve months:
(*Subcontractors are not covered unless added by endorsement)

4) (a) Please describe your Safety Consulting services below by showing the percentage of income derived from each and a brief description of each. (If your activities include "Training" not of the lecture variety, please provide full details).

(b) What percentage of the Applicants clients are in the following industries totaling 100%? 
0/100 points
(d) Do you perform any Safety Consulting activities off-shore or overseas?
(e) Does the Applicant perform Onsite Safety Surveys/Inspections?

5) Please provide prior carrier information for the last three (3) years:

(a) Commercial General Liability                                                                                                    LIMITS:
 Expiration DateCarrierPolicy NumberPolicy TypeGeneral AggregateProducts AggregatePer OccurrenceTotal Premium
(b) Professional Liability
 Expiration DateCarrierPolicy NumberLimitsDeductibleTotal Premium
(c) Any policy or coverage declined, cancelled or non-renewed during the prior three years?
6) Have any claims or suits been made during the past five years against the Applicant as either an individual or as a Safety Consultant:
Is Applicant aware of any circumstance which may result in a claim?


8) Policy Period Requested:
9) Policy Limits Requested (Per Occurrence/General Aggregate):
NOTE: ASSE Professional Liability must be maintained through our office in order to bind the ASSE General Liability. If you wish to bind the $2,000,000/$2,000,000 limit on the General Liability, Underwriters will require the ASSE Professional Liability must be at $1,000,000/$2,000,000 limits.
10) Is the applicant a member of the American Society of Safety Engineers?

I hereby declare the above statements and particulars are true, and that I have not suppressed or misstated any material facts.  At the present time, I have no reason to anticipate any claim being brought against me, other than as stated above, and agree this Proposal Form shall be the basis of the contract between myself and the Underwriters and shall be deemed a part thereof.

This Proposal Form duly completed, together with any supplementary information, must be signed in ink by the Applicant.
Completion of this Proposal Form does not obligate the Applicant or the Insurer to complete this insurance.

AIF 2391 A (10/08)