Contractor's Liability Quote

Underwriting Guidelines and Classes

Quote Urgency:  

Producer Info
Producing Agency:
Your Name:
Producer # (if applicable):
Producer Phone:
Preferred Response: (Req'd)
Agent's E-mail Address:
Billing Method:
Agent Bill    
Direct Bill - Insured
Check all that apply:
3 Month Policy - 100% Min. Earned Premium
6 Month Policy - 50%  Min. Earned Premium
12 Month Policy - 25% Min. Earned Premium

Applicant Info
Applicant Name and DBA
Audit Contact Name
**Office / Shop Address**
Audit Contact Phone
**Office / Shop City, State, Zip**
Best Contact Time
Mailing Address (if same as Location, enter "SAME")
Type of Ownership:
Mailing City, State, Zip (if same as Location, enter "SAME")

Type of Risk
Describe applicant's general operations:

List services performed and percentage:
Years in business: Years of experience in this field:
Does applicant have insurance in place right now? Yes   No  
Current Company: Current Premium:
List and describe all losses or claims in the past 3 years whether it was paid by the insurance company or not:
(If NONE - enter NONE below)

Specific Class Underwriting Questions
The following questions MUST be answered as they apply to the applicant's operations,
but ONLY answer this section if the applicant performs the work listed below:
Does applicant perform any roofing?  
Does applicant perform work on new construction?    
% Commercial?    % Residential?

Concrete Construction/Handyman
Does applicant perform any structural work?  

Electrical Work within Buildings/Handyman
Does applicant install or service any alarm systems?  
Does applicant perform any work other than electrical work within a building or incidental work outside the building?  

Does applicant use herbicides or pesticides that are NOT commonly sold?  
Does applicant provide only grass cutting / fertilizing / general clean up services?  
Does applicant do any snow plowing?

Does applicant perform any structural work or stucco applications? 

Does applicant perform any work on sewers or fire sprinkling systems?  

HVAC/Handyman (Heating / Venting / Air Cond.)
Does applicant install any fireplace or wood burning stove?  

General Business Information
Number of Owners:  
Number of Employees/Helpers:     (Do NOT include numbers of owners)
Employee/Helper Annual Payroll:    (Do NOT include owners' payroll)
Gross Annual Sales:      What percentage of work is Residential?      Commercial?
What percentage of your total sales is subcontracted to others?
    - If subcontractors apply, is applicant listed as an additional insured on their policy? Yes   No   N/A
   - Are the limits of coverages equal or exceeding those applied for?  Yes   No   N/A

Liability Coverages
Coverages Coverage Amount
General Liability Coverage (Occ / Agg)
Damages to Premises Rented to You $100,000 - Included
Medical Payments $5,000 - Included

Additional Insureds
There is a charge for additional insureds.  If the policy requires an additional insured, they must be entered below for quoted premium to be accurate.

General Underwriting Questions
1. Has the applicant ever filed for bankruptcy? Yes   No
2. Does applicant do excavation, tunneling, underground work, earth moving, blasting, or utilize explosive material? Yes   No
3. Has the applicant had any OSHA violations? Yes   No
4. Has the applicant ever been named in a lawsuit for defective workmanship? Yes   No
5. Does applicant's operations involve any EXTERIOR work performed over 3 stories in height? Yes   No   N/A
6. Has the applicant had any claims in the last 3 years whatsoever? Yes   No
7. Does the applicant do any child proofing or work in schools or hospitals? Yes   No
Explain any "Yes" answers:
Policy fee is fully earned at inception of policy.
Agent/Applicant warrants that above are true to the best of his/her knowledge.

 If you wish to have a copy of this submission for your records, you must print page BEFORE submitting.



Please note - There might be a delay upon submission.
Do not exit until you receive the "Confirmation Page."

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