EmailMe Form - Contractors Quote Request Form

Name

First Last

Phone:

### - ### - ####

Email

Business Name:

Contractor's License Number:

Your License Type:

Mailing Address:

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Physical Location Address:

Street Address City State / Province / Region Postal / Zip Code Country / Region

Desired insurance type

General Liability

Workers Comp

What % of your work is:

Residential

Commercial

Industrial

New Construction

Structural Remodeling/Additions

Non-structural Remodeling

Interior

Exterior

Estimated 12-month Gross Sales Receipts:

Estimated Annual Employee Payroll:

Number of owners, officers, and partners physically working at job sites:

Do you use subcontractors:

If so, specify the estimated annual % of work subcontracted:

Estimated annual sub-out cost (including labor & materials)$:

Subcontractors:
List the trade of each subcontractor you use and give the % of your work they perform:

Liability Limit:

$1M each / $1M aggregate

$1M each / $2M aggregate

$1M each / $3M aggregate

$2M each / $2M aggregate

Do you currently have insurance?

Yes

No

Current Insurance Company (not broker):

Expiring Date:

Any claim in the last 3 years (Yes/No)?
If so, please explain.

Number of Years Experience:

Brief Description of Your Work:

You need this coverage by

MM / DD / YYYY

Do You Work on New Tracts?:
(Remodel work on Tracts is not considered new Work)

Yes

No

Do You Work on NEW Condos, Townhouses or Apartments?
(Remodel work on condos or Townhouses and Apartments is not considered new Work)

Yes

No

Please describe your largest planned project in the next year, and amount?

Please describe your largest completed project in the last 3 years, and amount?

Any Additional Insureds? How Many? If known, please list here.