John Galt Insurance Agency

CNR Application

Company Information

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Description of your business

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Are you a Daycare 
or Private School? *
Do you currently pay in
excess of $10,000 annually
for all of your business 
insurance combined? *
Does your company currently offer Health 
Care, Life, Dental, Disability or a 401k plan
to your employees? *
Do you have any
company vehicles? *
Any insurance claims in the past year? *
Explain those claims in detail
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Insurance information

Type of coverage
 Amount of coverage requested
Boiler & Machinery (BMAC)
Business Owner's Policy (BOP)
Commercial Auto (CA-S)
Commercial E&O (CE&O)
Commercial Flood (CFLO)
Commercial Package (PCKG)
Commercial Umbrella (UM-S)
Commercial Wind (CWIN)
Cyber Liability (CYBE)
Difference in Conditions (DICP)
Directors & Officers (DIRL)
Equipment Floater (FLTR)
General Liability (GL-S)
Glass & Sign (GLAS)
Inland Marine (INLA)
Liquor Liability (LIQL)
Pollution Liability (POLL)
Property (PROP)
Workers' Compensation (WC-S)
Other
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Internal use only

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