IMPORTANT: THIS IS NOT A BINDER
Information provided in this application will be used only for the purpose of determining eligibility for coverage in a specific general liability and completed operations program. Stratus Insurance Services, Inc. and Security Group Intl. will not sell or otherwise provide your name and information to a third party for any reason other than for the purpose specified above.

NOTE: This is a 5-page form. Click the 'Proceed' button at the bottom of each page to continue to the end of the form. Do not leave any questions blank. If it does not apply, mark it “N/A.”

Section A: Applicant Information
Name of Insured as it is to appear on policy:
Business Mailing Address:
City:
State: Zip:
Phone: Fax: E-mail: Web site:
Name of Owner or Insurance Contact:
Are you a member of the Hearth, Patio and Barbecue Association?
Yes No
Are you a member of any other associations? If “yes”, please list:
Total experience in this type of business: years
Section B: Insurance Information
Current Insurance Company:
Expiration Date: Liability Premium:
Deductible Requested: Proposed Effective Date:
Have you ever had similar insurance cancelled or non-renewed?
Yes No
If yes, please explain:
What other types of Insurance does applicant currently have in place? (e.g. Auto, E & O, etc.)