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Contractors / Artisans Quote Application


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Contractors / Artisans Quote Application
* Required Information
Full Name:*  
E-mail Address:*  
Daytime Phone:*
MAILING ADDRESS
Street:
City:
State: Zipcode:*
Fax:
How would you like to be contacted?
Comments/Notes about your Insurance/Financial needs:
Name of Business:
DBA (if any):
BUSINESS ADDRESS (if different from above)
Street:
City:
State: Zip:
OTHER BUSINESS INFORMATION
Business Web Site Address
Year Business Started
Years Operating Under Current Name
Ever Filed Bankruptcy or Reorganization YES NO
Have you used other Business Names in the last 5 Years YES NO
Please Describe the
Nature of Your Business
# of Owners
# of Employees
Select Classification of Work
     Other Classifications 2
     Other Classifications 3
     Other Classifications 4
Contractors License #
License Type
Years of Experience
 FINANCIAL INFORMATION
Payroll of Employees
Annual Sub Costs
Annual Gross Receipts
 OPERATIONS INFORMATION
Have you been involved in the
original construction or remodeling of:
- Townhomes
- Condos / Coops
- Row Homes
- Developments of 15 or more
  single Family Homes		 YES NO
Do you construct footings or foundations
which may support dwellings or
other structures?		 YES NO
Do you construct slab or monolithic floors? YES NO
Do you construct piers or underpinnings
which may support dwellings or
other structures? 		YES NO
Do you construct retaining walls
which may support dwellings or
other structures? 		YES NO
Do you construct fireplaces or chimneys? YES NO
% of work done as GENERAL CONTRACTOR
% of work done as SUB-CONTRACTOR
% of work done on RESIDENTIAL
% of work done on COMMERCIAL
% of work done for REMODELING
% of work done for RENOVATION
% of work done for REPAIR/MAINT.
 COVERAGE INFORMATION
Losses-Claims in the Last 5 Years? YES No
If Losses and/or Claims
List - Date, Amount Paid and
Description of Each Loss
Liability Limits Requested
Other Loss Limit
Deductible
Other Deductible
Would you like Signage / Awning Coverage? YES No
 CURRENT INSURANCE COVERAGE INFORMATION
Carrier
Expiration Date
Premium
   

Thank you for completing this form
We will only use information provided to assist in obtaining appropriate insurance quotes and coverage.
We will not distribute information to other parties other than for insurance underwriting purposes.

* Insurance coverage cannot be bound or altered by this submission.

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