How did you hear about Brown's Insurance? * Please pick one I'm a current customer I Saw your Yellow Pages listing Pam Posey contacted me Bobby Tavenner contacted me Rick Brown contacted me I Saw your ad I Found you on the Internet Other

Business Name *

Contact Name *

Street Address

City, State, Zip

Telephone *

Fax

Email Address *

How many years has your company been in business? *   If you have been in business for less than 3 years Years Home Building Supervisory or Management experience?

Federal Employer ID Number? *

Payroll to Employees? *

Cost of Subcontractors? *

Gross Receipts? *

Do you require Certificates of Insurance from all Subcontractors? *    Yes   No   (We can only quote your General Liability if the answer is yes).

Do you require your Subcontractors to Add you as Additional Insured on their policy?    Yes   No   (We can only quote your General Liability if the answer is yes).

Do you have a formal, written Safety Program?    Yes   No   Must pick Yes or No   If you do not have a formal, written Safety Program Are you willing to work with an insurance company to install one?    Yes   No   (We can only quote your General Liability if you have, or are willing to start up a formal, written safety program).

Do you provide a Homeowners Warranty on all homes you build?    Yes   No   Must pick Yes or No   If you do not provide Homeowners Warranty at present Are you willing to provide them in the future on all homes you build?    NA   Yes   No   (We can only quote your General Liability if you do, or will provide homeowners warranties on all homes you build).

What percentage of your business is building Private Residential Buildings?

What percentage of your business is building Commercial Buildings?

What percentage of your business is building Town Houses, Condos, or Apartments?

What percentage of your business is outside of Virginia?

Have you had any Liability claims in the past four years? *    Yes   No   Must pick Yes or No   Date Amount Closed? Cause

Are you a member of any Builders Association?    Yes   No   Must pick Yes or No   If yes, what is its name?

Do you have General Liability Insurance now?    Yes   No   Must pick Yes or No   If yes, who writes it?   If yes, is it being cancelled for any reason?    NA   Yes   No   Must pick Yes or No if prior answer is Yes

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