| Business Name | |
| License # | |
| License Type | |
| Address | |
| City | |
| Zip | |
| State |
|
| Phone # | |
| Fax # | |
| Cell Phone # | |
| Email Address | |
| Person to Contact Re: Insurance | |
| Best Time To Call | |
| My Company Is: | Sole Proprietorship
Partnership
Corporation |
| How many active Owners/Partners/Officers perform hands-on construction work? | |
| Do you have any employees working in the field? | Yes
No |
| If Yes How Many? | |
| My years of experience in this field is: | |
| I am interested in the following types of insurance coverage: |
General Liability
Worker's Compensation
Commercial Auto
Tools / Equipment
Errors & Ommissions
Property i.e. Buildings
|
| OPERATION: Please describe the work you plan to do | |
| What percent of Commercial Work do you plan to do next year? | % |
| Break Down of Commercial Work: |
% New Construction
% Service & Repair
% Remodel
|
| What percent of Residential Work do you plan to do next year? | % |
| Break Down of Residential Work: |
% New Construction
% Service & Repair
% Remodel
|
| Gross Receipts | $ (Cost of materials, sub-contract work, labor, profit) |
| Field Payroll | $ (Exclude owners, officers, salespersons and clerical staff) |
| Approximate amount you will subcontract out to other contractors. | % |
| If you plan on hiring subcontractors, what will they do for you? | |
| What limits of liability are you interested in? |
$100,000 / $300,000
$500,000 / $1,000,000
$1,000,000 / $1,000,000
$1,000,000 / $2,000,000
(Limits reflect per Occurrence and Aggregate Totals)
|
| Please indicate your anticipated work percentage for the next 12 months for each of the following trades: |
% Burglar Alarm Install
% Carpentry (Finish)
% Carpentry (Rough)
% Chimney Cleaning
% Concrete (Flat)
% * Concrete (Slab / Foundation)
% Debris Removal (Site)
% Demolition (Soft)
% Demolition (hard)
% Door, Window, Millwork Install
% Millwork Install
% Driveway, Sidewalk Paving
% Electrical
% Elevator
% * Excavation
% Fencing
% Fiber Optics
% Fire Restoration
% Fire / Security Alarms
% Flooring
% Gas Lines
% * Grading
% Guniting / Shot-Crete
% Handy Man
% HVAC
% Insulation
% Landscaping
% Masonry
% Metal Erection (Steel / Iron)
% Mold Remediation
% Paint Interior
% Paint Exterior
% Plumbing Residential
% Plumbing Commercial
% Refrigeration Systems
% Retaining Walls
% Roofing
% Sewer Tie-In / Repair
% Siding Installation
% Solar Energy Systems
% Swiming Pool Construction
% Swimming Pool Cleaning
% Telephone / TV / Radio Line Install
% Termite / Dry Rot Repair
% Tile / Stone / Marble
% Tree Trimming
% Tree / Stump Removal
% Welding
% Other
% Other
Total of all work should equal 100%
|
| Do you perform work below grade?: |
Yes
No
|
| If "Yes", what is the maximum depth in feet you will work? | ft |
| Will any of your work be related to Brand New Ground-Up construction of Tract Homes, Condominiums, or Apartments? |
Yes
No
|
| If "YES", give a brief summary of the type of work planned and the percentage of your overall Gross Receipts: | |
| Do you plan on doing any service/repair work on existing condo's or apartments? |
Yes
No
|
| If "YES", please describe the work planned and the percentage of your overall Gross Receipts: | |
| Will you perform any work at AIRPORTS, GAS STATIONS, RAILROADS, or HOSPITALS? |
Yes
No
|
| If "YES", please describe: | |
| Do you have a liability policy in force? |
Yes
No
|
| Expiration Date | |
| Insurance Company | |
| How soon would you like to obtain General Liability insurance? | |
| Have you had any prior claims, losses or litigation related to your current or past construction operations? |
Yes
No
|
| If "YES", please describe the circumstances involved: | |
| How many Additional Insured certificates do you expect to need this year? | |
| Please indicate if you would like to receive a quote on other insurance coverage for your Business Auto, Contractor's tools & Equipment, Building, Business Personal Property or Workers' Compensation insurance (an Agent will contact you to discuss these options): |
Yes
No
|
|
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