Name of Insured:
E-MAIL Address:
Type of Entity:
Individual Partnership Corporation LLC
Name of Owners/Officers:
How long have you been in business?
If less than three years, how long have you been doing
this type of work?
What kind of work do you do (be as specific and detailed as possible?)
How many employees do you have in addition to the owners?
What is your expected annual payroll to
employees other than the owners (total for all employees)?
Do you use sub-contractors? Yes No
If you use subs, how much would you expect to pay
to all subs over the next 12 months?
Do you require certificates of insurance
from your sub contractors? Yes No
If yes, how often do you require certificates of insurance
from your sub contractors? Most of the time. Some of the time.
Do you require that the sub name you
as additional insured for general liability? Yes No
If you use uninsured subs or piece workers,
how much would you expect to pay to all
insured subs over the next 12 months ;
uninsured subs over the next 12 months ?
What limit of liability do you want for the general liability?
$300,000 $500,000 $1,000,000 $2,000,000 More
Do you want work comp coverage? Yes No
If yes, do the officers/owners wish to be covered? Yes No
Do you have an experience modification factor for work comp?
Yes No Don't Know
If yes, what is it?
How much coverage do you want for office contents
or building materials in storage?
Do you want coverage for any buildings used in business?
Keep in mind that normal homeowners policies exclude other
structures used in whole or in part for business. Yes No
If yes, how much coverage?
Do you currently have business insurance? Yes No
If yes, through what companies and expiration date?
If you have had any claims in the last three years,
please provide the details:
Please provide a name and phone number where we can
contact you to send you the quote:
Name:
Voice Phone Number:
Fax Number:
Please add any remarks or additional information
that you think is important for us to provide a quote.
|