Due to the Coronavirus, our office will be operating remotely in order to keep our staff free from infection. For latest update on the virus as it pertains to Florida please access our link. Office: 813.995.6013 Ext: 101 / Direct: 727.755.3060 Email: info@centurioninsuranceafs.com

General Liability Insurance Application

    General Information













    IndividualPartnershipJoint VentureTrustLimited Liability CompanyOrganization (Other than Partnership, Joint Venture, or Limited Liability Company)


    YesNo





    YesNo




    YesNo


    YesNo


    YesNo


    YesNo


    Criminal BackgroundDriving RecordDrug ScreenFingerprint CheckPolygraphPrior Employment ContactedPsychological TestOther


    YesNo







    YesNo



    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    Coverage & Limits Section


    $1M/$2M$1M/$3M$1M/$4M$1M/$5MOther


    $0$1,000$2,500$5,000


    Additional InsuredEmployee Benefits LiabilityHired/Non-owned AutoPer Project AggregatePrimary WordingStop GapWaiver of Subrogation


    YesNo

    If excess/umbrella coverage is required please complete the excess portion of the application

    Security Guard Section



    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo

    Operations












































































    Detective/PI Section



    YesNo


    YesNo


    YesNo


    YesNo

    Operations








































    Policy Information

    Carrier






    Premium






    Payroll






    Deductible






    Incurred Losses







    YesNo


    YesNo


    YesNo



    Additional Operations Information

    Airports



    YesNo


    YesNo


    YesNo


    YesNo

    Executive Protection/Bodyguarding


    YesNo

    Special Events



    YesNo


    YesNo


    Apartments/Residential




    YesNo

    Schools & Colleges



    YesNo


    YesNo


    YesNo

    Restaurants





    YesNo


    YesNo

    Signature Section