On-Line Contractors Liability Quote Form
One Simple Form - takes only 2-3
Minutes!
|
Your
Name: |
|
BUSINESS
Name: |
|
Mailing
Address: |
|
City:
|
|
Province:
|
|
Postal:
|
|
E-Mail
(REQUIRED): |
|
Phone:
|
|
Fax
(optional): |
|
|
|
Business Underwriting justquotesrmation |
Type
of operation: |
|
Describe
operations in detail: |
|
License
class: |
|
License
Number: |
|
|
|
Limit of
Liability
Coverage Requested? |
$500,000
$1 Million
$2 Million |
Select Any Optional coverages You'd Like Quoted:
Directors and Officers Coverage
Professional or Errors and Omission Coverage
Group Health Insurance Coverage
Workers Compensation Coverage
Business Auto/Vehicle Coverage
Business Property Coverage
Disability Coverage
Life Insurance Coverage
|
|
|
Currently
Insured? |
Yes
No |
Name
of Carrier & how long insured? |
|
Prior
Claims? |
Yes
No |
Describe
claims in detail: |
|
|
|
Years
in business: |
|
Years
experience in field: |
|
Percentage
of work residential: |
|
Percentage
of work commercial: |
|
|
|
Number
of Active Owners: |
|
Number
of Employees: |
0
1
2
3+ |
Annual
Employee Payroll: $ |
|
Annual
Gross Sales: $ |
|
|
|
Do
you subcontract work? |
Yes
No |
(If
yes, what percentage of your work
is subbed, and what kind of work?) |
|
Do
you do foundation work? |
Yes
No |
Do
you work on condos? |
Yes
No |
Employees
paid over $18/hour? |
Yes
No |
Do
you have a safety program? |
Yes
No
|
Comments/Remarks: |
|