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Michael W. Smith Agency

Revised:

May 06, 2015

Contractor

763-535-7293

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Information

Let me know about special concerns you have.

Builder / Contractor / Developer / Construction
MN Liability & Property Insurance
Quote Request Form

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This is a request for a Minnesota Contractors / Developers / Builders
Construction insurance quote, not a policy application. Submitting this form does not obligate you to purchase any insurance products. Please complete this form as accurately as possible. Contractor insurance rates are subject to change.

Contact Information

Contact Name
Company Name
Street
City, State ZIP
        
E-mail
Phone
Cell Phone
Fax
Web Address

Company Information

Form of Business
Years in Business
Years Experience in Business
Contractor's License #
Type of License
Please describe your
business operations in detail

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Insurance Information

Effective Date Needed
Years of Loss Runs Available

Insurance Carrier Information
(if you have no previous insurance, enter "none" for the Year)

Year Carrier Policy Number Limits Premium

Loss History

Check here if no losses in the past 5 years none

Please describe any losses you've had in the past five years.

Date of Loss Type of Loss Description of Loss Amount Paid Reserve

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Liability Coverage Request

Limits of Liability
Property Damage Liability Deductible
Umbrella

Property Coverage Request
Enter the total amount of coverage you are requesting for each category below.
Skip this section if you are not requesting property coverage.

Property Coverage Amount of
Coverage		 Property Coverage Amount of
Coverage
Tools Mobile Equipment
(Bobcat, forklift, etc.)

Laptop Computers Other Equipment

Other Computer
Equipment		 Office Equipment
& Supplies

Building Materials at
Applicant's Location		 Building Materials
at Job Site

Buildings
Under Construction		 Buildings
Completed
For Sale

Buildings Owned
& Occupied by
Applicant

Other Property
(please explain and
provide values)

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Underwriting Questions

General Information I

Explain all "Yes" responses Yes No Explain all "Yes" responses Yes No
Are you a subsidiary of another entity
or do you have any subsidiaries?		 Any exposure to flammables,
explosives, chemicals?
Any operations sold, acquired,
or discontinued in last five years?		 Have you been active in or are you
currently active in joint ventures?
During the past three years, has any
company ever cancelled, declined or refused
to issue any similar insurance to you?		 Any bankruptcies, tax or credit liens
against you in the past five years?
Explain all yes responses

General Information II

Please answer the following questions Yes No Explain all "Yes" responses
Do you perform any out of state work?
If yes, in what states and provide details
of work performed.
Have you ever used, sold,
installed or removed asbestos?
Do you draw plans,
designs or specifications?
Do you have mobile equipment
that travels over public roads?
Do you perform or subcontract
fire restoration and/or water
remediation work?
Have you ever operated
under any other name(s)?
If yes, give names, addresses
& years of operation.

Do you perform work below grade?
If yes, explain % of work
and maximum depth.
Have you ever been involved in or are
you aware of pending litigation against
any named insured concerning construction
defect or fungus/mold claims?

List anticipated gross sales for the current term
& sales for the past three years.

Year

Gross Sales
Current

20

20

20

Indicate the percent of each type of work performed

Type Commercial Residential Industrial % of Total
Operations
New Construction % % % %
Renovation % % % %
Real Estate
Developer		 % % % %

Of the work Indicated above, please enter the percentage of
work you performed as a General Contractor or as a Subcontractor

General Contractor Subcontractor
% %

If you have ever been involved as a General Contractor in the building
of Residential homes, Condominiums, Townhouses or Apartment Buildings
enter the maximum number built in any 12-month period in the past five years

Residential Homes Condominiums
Townhouses Apartment Buildings

Indicate whether the following trades on a typical project are
performed you & your employees or by subcontractors
E - performed by you & your employees or S - performed by subcontractors

Description E Annual
Payroll		 S Annual
Cost		 Description E Annual
Payroll		 S Annual
Cost
Bridge Construction Insulation
Carpentry Interior demolition
Concrete Landscaping
Debris Removal Masonry
Drilling Painting
Drywall Parking lot paving
Electrical Plumbing
Excavation Roofing
Framing Siding
Grading Street Paving
Guard rail installation Stucco
HVAC Other

Special Hazards - Do any of your operations involve the following?

Explain all "Yes" responses Yes No Explain all "Yes" responses Yes No
Use of cranes Blasting
Use of tower cranes
Length of booms in feet		 Foundation repair
ft Shoring or underpinning
EIFS (Exterior Insulation & Finish Systems) Pile driving
Demolition of structures (other than interior) Caisson or cofferdam work
Structural alterations Other special hazards
Explain all yes responses

Property
If you are not requesting property coverage
click here: Finish

Buildings Under Construction
Property #1

Address City State Zip Code
Expected
Completion
Date		 Estimated
Completed
Value		 Type of
Building		 Construction
of Building
Responding Fire Department Miles to Fire Department Feet to Fire Hydrant

Buildings Under Construction
Property #2

Address City State Zip Code
Expected
Completion
Date		 Estimated
Completed
Value		 Type of
Building		 Construction
of Building
Responding Fire Department Miles to Fire Department Feet to Fire Hydrant

Buildings Under Construction
Property #3

Address City State Zip Code
Expected
Completion
Date		 Estimated
Completed
Value		 Type of
Building		 Construction
of Building
Responding Fire Department Miles to Fire Department Feet to Fire Hydrant

Completed Buildings For Sale
Property #1

Address City State Zip Code
Date
Completed		 Current
Value		 Type of
Building		 Construction
of Building
Responding Fire Department Miles to Fire Department Feet to Fire Hydrant

Completed Buildings For Sale
Property #2

Address City State Zip Code
Date
Completed		 Current
Value		 Type of
Building		 Construction
of Building
Responding Fire Department Miles to Fire Department Feet to Fire Hydrant

Completed Buildings For Sale
Property #3

Address City State Zip Code
Date
Completed		 Current
Value		 Type of
Building		 Construction
of Building
Responding Fire Department Miles to Fire Department Feet to Fire Hydrant

Buildings Owned & Occupied by Applicant
Property #1

Address City State Zip Code
Year
Built		 Current
Value		 Type of
Building		 Construction
of Building
Responding Fire Department Miles to Fire Department Feet to Fire Hydrant

Buildings Owned & Occupied by Applicant
Property #2

Address City State Zip Code
Year
Built		 Current
Value		 Type of
Building		 Construction
of Building
Responding Fire Department Miles to Fire Department Feet to Fire Hydrant

Thank you for taking the time to complete the contractor quote request form.
Please enter any comments below then click on the submit button.

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Additional Comments

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Number of hits since August 15, 1998

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