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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

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

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)

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
Use of tower cranes Length of booms in feet	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:

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

Contractor / Developers Liability & Property Insurance Quote Request Form

Contact Information

Company Information

Contractor / Developers
Liability & Property Insurance
Quote Request Form