Liability Quote
 
 

General Information
Name of Business:
Inspection Contact Name:
Mailing Address:
 
City:
  State:   Zip:
Location Address:
 
City:
  State:   Zip:
Business Phone:   Fax:
Contact Email Address:
Business Status:     Years in Business:

Current Insurance Information
Company Name
(not agency):		     Premium: $
Effective Date:   Expiration Date:
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:
What percentage of your work is: 
(each line must total 100%) 		 Commercial %
Industrial %
Residential %
New Construction % Remodel/Additions %
What percentage of your work is as a:  General Contractor: % Subcontractor: %
What percentage of your work is: Subcontracted Out: %
Sub Costs: $
Do you collect certificates of insurance at a $1,000,000 limit?:   Yes     No

Receipts / Payroll / Dollar Value Info
Gross receipts for the past 3 years: 
and the next 12 months: 

(3rd yr prior) $ 
(2nd yr prior) $
(Last 12 mths) $ 
(Next 12 mths) $
Number of owners/officers/partners active at the job site or supervising:     
Payroll of employees excluding 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

 

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