Question 1.

In regards to your last five years of General Liability Insurance... Do you what type of "liability form" you have carried?

• YR 1. Please select from list full occurrence modified occurrence claims-made I do not know
• YR 2. Please select from list full occurrence modified occurrence claims-made I do not know
• YR 3. Please select from list full occurrence modified occurrence claims-made I do not know
• YR 4. full occurrence modified occurrence claims-made I do not know Please select from list
• YR 5. full occurrence modified occurrence claims-made I do not know Please select from list

Question 2.

Can you determine for how many years you would have protection after your current policy term expires?

• YR 1. Please select from the list I do not know the answer none unless I purchas tail coverag one year after current term two years after current term three years after current term four years after current term five years after current term ten years after current term
• YR 2. Please select from the list I do not know the answer none unless I purchas tail coverag one year after current term two years after current term three years after current term four years after current term five years after current term ten years after current term
• YR 3. Please select from the list I do not know the answer none unless I purchas tail coverag one year after current term two years after current term three years after current term four years after current term five years after current term ten years after current term
• YR 4. Please select from the list I do not know the answer none unless I purchas tail coverag one year after current term two years after current term three years after current term four years after current term five years after current term ten years after current term
• YR 5. Please select from the list I do not know the answer none unless I purchas tail coverag one year after current term two years after current term three years after current term four years after current term five years after current term ten years after current term

Question 3.

Do you know the Rating of your Insurance Company for the last five years? If so, please choose from the list.

• YR 1. Please select from the list Admitted A- I to A XV Non-admitted A- I to A IV Admitted B- I to B+ IV Non-admitted B- I to B+ IV RRG Risk Retention Group not rated RRG Risk Rention Group Rated A RRG Risk Retention Group Rated B Other
• YR 2. Please select from the list Admitted A- I to A XV Non-admitted A- I to A IV Admitted B- I to B+ IV Non-admitted B- I to B+ IV RRG Risk Retention Group not rated RRG Risk Rention Group Rated A RRG Risk Retention Group Rated B Other
• YR 3. Please select from the list Admitted A- I to A XV Non-admitted A- I to A IV Admitted B- I to B+ IV Non-admitted B- I to B+ IV RRG Risk Retention Group not rated RRG Risk Rention Group Rated A RRG Risk Retention Group Rated B Other
• YR 4. Please select from the list Admitted A- I to A XV Non-admitted A- I to A IV Admitted B- I to B+ IV Non-admitted B- I to B+ IV RRG Risk Retention Group not rated RRG Risk Rention Group Rated A RRG Risk Retention Group Rated B Other
• YR 5. Please select from the list Admitted A- I to A XV Non-admitted A- I to A IV Admitted B- I to B+ IV Non-admitted B- I to B+ IV RRG Risk Retention Group not rated RRG Risk Rention Group Rated A RRG Risk Retention Group Rated B Other

Question 4.

Does your company provide protection for you in any way if your sub-contractor does not do any of the following?

• a. Name you as additionally insured Yes No select
• b. Carry the same limits as you do? Yes No select
• c. Meet the Ratings set by your policy? Yes No select

Company name