General Information
Name of Business:
Inspection Contact Name:
Mailing Address:
City:   State:   Zip:
Location Address:
City:   State:   Zip:
Business Phone:   Cell Phone:   Fax:
Contact Email Address:
Business Web Address:
Business Status:     Years in Business:
Federal ID/EIN #:


Current Insurance Information
Company Name (not agency):     Premium: $
Effective Date:   Expiration Date:
Years of Continuous Insurance:
Liability Limits:
Please List Any Other Previous Carriers Over the Past 3 Years Below:
Carrier Name:     Premium: $
Carrier Name:     Premium: $


Project/Work Information
Please write a Description of Operations below:
Please list percentages for each category below. Each column must add up to 100%.
% of your work that is: % of your work that is: % of work you do as:
Commercial %
Industrial %
Residential %
100%		 New Construction %
Remodel/Additions %
100%		 General Contractor: %
Subcontractor: %
100%
What % of your work is Subcontracted out?: %
Please list your Subcontractor Costs: $
Do you require all Subcontractors to carry limits of liability equal to your own?:   Yes     No


Receipts / Payroll / Dollar Value Info
Gross receipts for the past 3 years and the next 12 months: (3rd yr prior) $
(Last 12 mths) $		 (2nd yr prior) $
(Next 12 mths) $
Number of owners/officers/partners active at the job site or supervising:   
Payroll of employees: 
(excluding owners, officers, partners & clerical) 		  $
Payroll of owners, officers, partners & clerical:   $
Dollar value of average job completed incl. all materials, labor & equipment:  $
Describe any project(s) underway or planned for the next year, including values below:


Miscellaneous and Legal Info
Have you ever performed ground up construction involving condominiums, townhouses, apartments, or single family tract developments of two (2) or more?:    Yes 
  No 
Have you ever been named in litigation regarding faulty construction?:    Yes 
  No 
Are there any claims or legal actions pending?:    Yes 
  No 
Do any of the entities named in the application have knowledge of any pre-existing act, omission, event, condition or damages to any person or property that may potentially give rise to any future claim or legal action against any such entity?:    Yes 
  No 

 
Claims History
Enter all claims or occurrences that may give rise to claims for the prior 3 years.
This information is kept strictly confidential

Claim #1
   Claim Status: Closed   Open
Date of Occurrence:   Date of Claim:
Type/Description of Occurrence or Claim:
Amount paid on your behalf: $   Amount reserved on behalf: $

Claim #2
   Claim Status: Closed   Open
Date of Occurrence:   Date of Claim:
Type/Description of Occurrence or Claim:
Amount paid on your behalf: $   Amount reserved on behalf: $

 
Additional Comments
Please give any additional comments you feel appropriate for this quotation. If you have
additional information where there was not enough space, please enter them here.


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