Business Name License # License Type Address City Zip State Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Flordia Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming 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