PLEASE ANSWER THE FOLLOWING QUESTIONS FOR YOUR INSURANCE QUOTE

1  
 
Business Name Quote Needed By
Owners Name Years Of Exp.
Address (No P.O. Box)
City State Zip County
 
2  
 
Phone Number Fax Number Cell/Pager Number
Active E-mail Address       
Preferred Method Of Contact
Mail Fax Phone E-mail
 
3  
 
Lic. # or App. Fee # Classification Entity (check one)

Partnership
Sole Owner
Corporation
 
4  
 
Describe The Scope Of Your Work/Operation
Number Of Owners Active In The Field:
Number Of Employees
Full Time:
Part Time:
Percentage Of Commercial Work:    %
New Construction % Remodel % Service Repairs %
Percentage Of Residential Work:    %
New Construction % Remodel % Service Repairs %
IF YOU ARE A PAINTER OR ELECTRICIAN:
Percentage of inside work % Percentage of outside work %
       
5  
 
What Trades Do You Sub Out?
Percentage Of
Commercial Work:		   %
Percentage Of
Residential Work:		   %
 
6  
 
Your Financial Estimate For The Next 12 Months
Gross Receipts 
Field Payroll       Subcontractor Cost  
 
7  
 
Do you plan to work on: (Please check all that apply)
New Contract Homes Condos Apartments
Number Of Units Per Project    Percent Of Gross Receipts   %
Do you do any roofing or roofing repairs Yes No
 
8  
 
What limits of general liability are you interested in? (Check choice/choices)
$300,00/$500,000 $500,000/$1,000,000
$1,000,000/$1,000,000 $1,000,000/$2,000,000
Carrier with a rating of: Current Carrier: Policy Expires: