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General Info
Contact Name *
Contact Name
Phone Number *
Phone Number
Lines of Business Proposed *
Can you tell us what you do? A brief explanation will suffice, we just want to know about your operations so we can recommend the proper coverages in our quote.
Please list the states where contracting is performed
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Coverage Date
Coverage Date
What effective date would you like us to use for our quote?
How many years have you been in business?
Who is your current insurance carrier?
Have you had any claims in the last 5 years? If so, please provide a detailed description of each claim along with approximately how much money has been paid out for each occurrence.
Approximately what percentage of your annual work would be considered as "residential" work?
Approximately what percentage of your annual work performed would be considered as "commercial" work?
General Liability
One way that insurance carriers rate your general liability premium is based upon annual sales. Please list your annual sales (ie: $4,000,000) and "subdivide" them per line items as well if possible ($500,000 for office employees, $300,000 for salespersons, $250,000 for window installation, etc.)
Employee 1
For quoting purposes, it would be helpful to know the specific info that applies to your employees and the info that applies to the owner(s). So if you're an owner, please indicate this within the "Job / Duties" box below.
Name
Name
Please indicate the official job title for this person, as well as a description of the duties performed for the company.
For quoting purposes, let's assume that "full-time" status is 30 hours per week or more, and "part-time" status is less than 30 hours per week.
What is the estimated annual gross payroll for this person?
$
Does this person drive vehicles that are titled in the company's name?
Employee 2
If you do not have any additional employees, feel free to skip down to the "Subcontractors" section below.
Name
Name
Please indicate the official job title for this person, as well as a description of the duties performed for the company.
For quoting purposes, let's assume that "full-time" status is 30 hours per week or more, and "part-time" status is less than 30 hours per week.
What is the estimated annual gross payroll for this person?
$
Does this person drive vehicles that are titled in the company's name?
Employee 3
If you do not have any additional employees, feel free to skip down to the "Subcontractors" section below.
Name
Name
Please indicate the official job title for this person, as well as a description of the duties performed for the company.
For quoting purposes, let's assume that "full-time" status is 30 hours per week or more, and "part-time" status is less than 30 hours per week.
What is the estimated annual gross payroll for this person?
$
Does this person drive vehicles that are titled in the company's name?
Employee 4
If you do not have any additional employees, feel free to skip down to the "Subcontractors" section below.
Name
Name
Please indicate the official job title for this person, as well as a description of the duties performed for the company.
For quoting purposes, let's assume that "full-time" status is 30 hours per week or more, and "part-time" status is less than 30 hours per week.
What is the estimated annual gross payroll for this person?
$
Does this person drive vehicles that are titled in the company's name?
Employee 5
If you do not have any additional employees, feel free to skip down to the "Subcontractors" section below.
Name
Name
Please indicate the official job title for this person, as well as a description of the duties performed for the company.
For quoting purposes, let's assume that "full-time" status is 30 hours per week or more, and "part-time" status is less than 30 hours per week.
What is the estimated annual gross payroll for this person?
$
Does this person drive vehicles that are titled in the company's name?
Employee 6
If you do not have any additional employees, feel free to skip down to the "Subcontractors" section below.
Name
Name
Please indicate the official job title for this person, as well as a description of the duties performed for the company.
For quoting purposes, let's assume that "full-time" status is 30 hours per week or more, and "part-time" status is less than 30 hours per week.
What is the estimated annual gross payroll for this person?
$
Does this person drive vehicles that are titled in the company's name?
Employee 7
If you do not have any additional employees, feel free to skip down to the "Subcontractors" section below.
Name
Name
Please indicate the official job title for this person, as well as a description of the duties performed for the company.
For quoting purposes, let's assume that "full-time" status is 30 hours per week or more, and "part-time" status is less than 30 hours per week.
What is the estimated annual gross payroll for this person?
$
Does this person drive vehicles that are titled in the company's name?
Employee 8
If you do not have any additional employees, feel free to skip down to the "Subcontractors" section below.
Name
Name
Please indicate the official job title for this person, as well as a description of the duties performed for the company.
For quoting purposes, let's assume that "full-time" status is 30 hours per week or more, and "part-time" status is less than 30 hours per week.
What is the estimated annual gross payroll for this person?
$
Does this person drive vehicles that are titled in the company's name?
Employee 9
If you do not have any additional employees, feel free to skip down to the "Subcontractors" section below.
Name
Name
Please indicate the official job title for this person, as well as a description of the duties performed for the company.
For quoting purposes, let's assume that "full-time" status is 30 hours per week or more, and "part-time" status is less than 30 hours per week.
What is the estimated annual gross payroll for this person?
$
Does this person drive vehicles that are titled in the company's name?
Employee 10
If you do not have any additional employees, feel free to skip down to the "Subcontractors" section below.
Name
Name
Please indicate the official job title for this person, as well as a description of the duties performed for the company.
For quoting purposes, let's assume that "full-time" status is 30 hours per week or more, and "part-time" status is less than 30 hours per week.
What is the estimated annual gross payroll for this person?
$
Does this person drive vehicles that are titled in the company's name?
Subcontractors
A subcontractor is a business or person that carries out work for a company as part of a larger project.
Subcontractor 1
If subcontractors are not used, please skip this section and proceed to the "Property" section below.
Name
Name
Please indicate the official job title for this person, as well as a description of the duties performed within their company.
What is the approximate annual gross cost that your company pays this subcontractor?
$
Do you require that your subcontractor provide you with a certificate of insurance each year before they perform any work for you?
Subcontractor 2
If subcontractors are not used, please skip this section and proceed to the "Property" section below.
Name
Name
Please indicate the official job title for this person, as well as a description of the duties performed within their company.
What is the approximate annual gross cost that your company pays this subcontractor?
$
Do you require that your subcontractor provide you with a certificate of insurance each year before they perform any work for you?
Property
If property coverage is not desired, feel free to skip down to the next eligible section.
If you own your building or condo, how much coverage would you like on it?
$
How much coverage would you like for your business personal property?
$
There is a different way to cover the tools that leave your company's premises and are taken onto the job site. And by "tools," we're referring to hand tools that are valued at $1,000 or less per item. How much coverage (if any) would you like a quote for on this?
$
This is basically the same concept as above, except that we're referring to items that are over $1,000 in value when we are referring to "Equipment" that is taken off premise and onto the job site.
$
An installation floater is an insurance policy that covers personal property installed, fabricated or erected by a contractor. It covers the property until the installation work is accepted by the purchaser or when the insured's interest in the property installed ceases. For example, assume I'm a carpenter and I've purchased cabinets to install for a client's kitchen. If these cabinets were stolen out of my truck before they were installed, I would have no coverage unless I had an installation floater endorsement on my policy. Is this coverage is desired, how much coverage would you like?
IF Building &/Or Contents Coverage is Needed...
If coverage is not needed, feel free to skip down to the next section below
Address of Building
Address of Building
Approximately what year was your building built?
Approximately how many years old is your roof?
Whether you own the entire building, or if you're a condo unit owner, or even if you're a tenant, we're looking for the total square footage of the entire building.
In this section, we're only looking the the approximate square footage of the area you inhabit within the building.
If there are other tenants within your building, we'll need to know their business names as well as what they do.
Commercial Auto
If this section doesn't apply, feel free to skip
Please list the year, make, model, and VIN for each vehicle that you would like coverage for. Please also indicate which vehicles should have full coverage (collision & comp deductibles) and which should have liability only.
If your car is damaged or destroyed in an accident, collision insurance coverage will typically pay to fix or replace it. Types of covered accidents include hitting another car or hitting a stationary object, like a bridge or a tree.
With Comprehensive coverage, your insurance company pays for damage to your auto caused by an event other than a collision, such as fire, theft or vandalism. If you hit an animal, or if your auto is flooded or stolen, Comprehensive coverage will apply.
Non-owned and hired automobile liability insurance covers bodily injury and property damage caused by a vehicle you hire (including rented or borrowed vehicles) or caused by non-owned vehicles (vehicles owned by others, including vehicles owned by your employees).
Workers Compensation
An owner of a business has the option to exclude themselves from their Work Comp coverage and thus save some money on their premiums. If you would like to take this option, please list each owner, their annual payroll, and the type of work they are specifically engaged in (ie: office work, sales, in the field, etc.)
Please list each classification along with its corresponding payroll. For example, you may have a "clerical" classification for your office employees with a corresponding payroll of $100,000, or a "salespersons" classification for your sales force with a payroll of $50,000.
This coverage provided by part 2 of the workers compensation policy provides coverage to the insured (employer) for liability to employees for work-related bodily injury or disease, other than liability imposed on the insured by a workers compensation law.
Commercial Umbrella
A business umbrella policy picks up where your business auto liability, general liability or other liability coverage stops. Umbrella insurance is an inexpensive way to provide extra coverage against bodily injury and/or property damage.
Is there anything else that you would like us to know?