Quote Form - General Liability Insurance for Contractors
Fields marked * are required.
Contractor License Number: *
Insured / Contact: *
Company Name: *
Phone: *
Fax:
Email: *
Policy Term Requested:
 
Mailing Address Premise Address (if different)
Address
* 		Address
City
* 		City
State
* 		State
Zipcode
* 		Zipcode
 
Payroll excluding Owners, Officers & Clerical
Job Classification: Expected Salary: Avg. Hourly Wage:

 

Please type Job Class here if not listed:
 $ $

 

Please type Job Class here if not listed:
 $ $

 

Please type Job Class here if not listed:
 $ $

 

Please type Job Class here if not listed:
 $ $
Gross receipts for the next 12 months and last 12 months
Previous 12 Months:
$ 		Next 12 Months:
$
 
Describe your operations:
Number of owners, officers, and partners active at job sites or performing supervisory duties
 
Do you have or have you had insurance coverage?
Carrier Name and Policy Number:
Expiration Date:
How Many Years of Prior Coverage?
 
Required Coverage Limits:
$300,000 is minimum, but $1,000,000 is often the standard requirement
Other:
 
Do you need any special coverages, requirements, company rating, or wording?
If yes, please describe:
 
How many years of experience do you have?
In contracting business:
In business of entities seeking coverage:
 
What percentage of your work is: (each line must add to 100%)
Residential:
% 		Industrial:
% 		Commercial:
%
New Construction:
% 		Structural remodel/additions:
% 		Non-structural remodel:
%
 
What percentage of your work is as a:
General Contractor:
% 		Subcontractor:
% 		Construction Manager:
%
Do you use subcontractors?
% of your work subcontracted out:
%
% annual costs of your work subcontracted out:
%
List the trades of the subcontractors you use and give the percentage of your work they perform:
1: %
2: %
3: %
 
List the States in which you operate (e.g.: CA, NV, AZ, etc.):
 
Describe your two largest projects currently underway or planned for the next year, including values:
1:
2:
 
Describe your two largest projects over the past five years, including values:
1:
2:
 
Dollar value of average job completed
Including all materials, labor & equipment:
$
 
How many new homes will you build as a general contractor in the next year?
  other:
What is the greatest number of new homes you have built in any one year?
  other:
 
The following question applies to work done in any capacity, including general contractor, developer, artisan, remodeling contractor, site work contractor, supplier, etc. remodeling contractor, site work contractor, supplier, etc.
Have you or will you perform work involving, related to, or about the premise of:
1: Condominiums or townhouses?
2: Apartments?
3: Tracts, PUD's, or any other development, premises or project with more than 7 homes built or planned?
4: Is this new construction from the groundup?

 

If "Yes", describe in detail:
5: Have or will any of your projects involve caissons, cantilevers, piers, retaining walls, shoring, underpinning, or other heavy structural engineering techniques?

 

If "Yes", describe in detail:

 

If retaining walls have been or will be built, maximum height:
ft.
6: Have you or will you build, remove, repair or replace roofs?

 

If "Yes", describe in detail:

 

Hot tar:%.  Torch:%.  Total:%.
7: Have you or will you work as a construction manager for a fee?
 
The following question applies regardless of whether you were at fault for a claim or incident, and regardless of whether the claim or incident was covered by insurance.
Have there been any losses, claims or suits against you in the past 5 years?

 

If "Yes", describe in detail:
 
Additional Comments:
 

 

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