|
Your Name:
|
|
|
Business Name:
|
|
|
Mailing Address:
|
|
|
City:
|
|
|
State:
|
|
|
Zip/Postal:
|
|
|
E-Mail (REQUIRED):
|
|
|
Phone:
|
|
|
Fax (optional):
|
|
|
|
|
|
Business Underwriting Information |
|
Type of operation:
|
|
|
Describe operations in detail:
|
|
|
License class:
|
|
|
License Number:
|
|
|
Employer ID#:
|
|
Describe work Done in %
(40% framing, 30% electrical,
10% drywall, 20% roofing, etc.):
|
|
|
|
|
Limit of Liability
Coverage Requested? |
|
|
|
|
|
|
|
|
Currently Insured? |
|
|
Name of Carrier & how long insured?
|
|
|
Prior Claims? |
|
|
Describe claims in detail:
|
|
|
|
|
|
Years in business:
|
|
|
Years experience in field:
|
|
|
Percentage of work residential:
|
|
|
Percentage of work commercial:
|
|
|
|
|
|
Number of Active Owners:
|
|
|
Number of Employees:
|
|
|
Annual Employee Payroll: $
|
|
|
Annual Gross Sales: $
|
|
|
|
|
|
Do you subcontract work? |
|
|
(If yes, what percentage of your work
is subbed?)
|
|
|
Do you do foundation work? |
|
|
Do you work on condos? |
|
|
Employees paid over $18/hour? |
|
|
Do you have a safety program? |
|
|
|
|
|
Comments/Remarks:
|
|
|
|
|
|
Send my quotation via: |
|