Quote - Contractors

Submitting Agency *

Agency Contact Name *

Named Insured *

Insured's Address *

Contractor Type *

New Venture *

Yes

No

New Venture = No

Declination - Has any carrier declined, cancelled, or non-renewed coverage during the prior 3 years? If yes, provide detailed explanation. *

Yes

No

Expiring Carrier *

Expiration Date *

Has Insured Had Losses? (Previous Five Years) *

Yes

No

Loss Runs = Yes

Attach loss runs for the past five years here *

Maximum upload size: 5MB

Years in Business *

Experience - Number of Years *

Licensing - Does insured have any and all licenses required for operations performed? *

Yes

No

Detailed Description of Operations *

General Aggregate *

Prod & Comps *

Personal & Advertising *

Occurence Limit *

Fire Legal *

Medical Expenses *

Deductibles (BI/PD) *

$ Total Receipts

# of Owners *

$ - Owner Payroll *

# of Employees *

Employee Payroll *

Subcontractors *

Yes

No

Subcontractors = Yes

Subcontractor Coverage - Has insured had losses? *

Yes

No

Subcontractors Operations - Provide detailed description of what operations are performed by subcontractors *

Types of Construction

% New Construction

% Remodeling

% Other

Types of Construction - Com/Resm

% Commercial

% Residential

Types of Construction - In/Out

% Inside Building

% Outside Building

Additional Insured

Additional Insured Name

Additional Insured Address

Additional Insured City

Additional Insured State

Additional Insured Zip

Relationship to Insured

Options

Add Waiver of Subrogation

Add Primary Non-Contributory

Quote – Contractors

Contractor Quote