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Request For Contractor Insurance
Quote
You can use this handy form to request
quotes on Business Package, Business Auto, Workers Compensation,
Umbrella policy.
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| Type of Organization: |
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| Name of Business: |
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| Contact Name: |
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| Address: |
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| City: |
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| State: |
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| Zip: |
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| Business Phone: |
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| Fax: |
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| Best Time To Call: |
AM
PM |
| Contact email address |
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| Description of Business: |
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| Annual Gross Sales/Revenue: |
$
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| Years in Business: |
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| Number of Employees: |
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| Annual Payroll: |
$
do not include owner's, clerical or sales
pay |
| % Residential: |
% |
| Commercial: |
% |
| Type of Business- (% revenue derived from following
sources): |
| Carpentry: |
% |
| Electrical: |
% |
| Painting: |
% |
| Plumbing: |
% |
| HVAC: |
% |
| Other: (explain in addl comments section below) |
% |
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| Current Insurance |
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| (if you now carry general liability insurance) |
| Policy Expiration Date |
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| Annual Premium |
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| Location to be covered: |
| Street: |
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| City: |
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| State: |
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| Zip Code: |
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| County: |
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| # of years at this location: |
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| # of additional locations: |
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| Value of Contents (office and/or shop): |
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| Property Coverages Needed: |
| Building Coverage Amount: |
$
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| Property Deductible: |
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Installation Floater:
(covers materials at job site, in transit and temporary storage
plus inventory for installation) |
| Average value of jobs in progress: |
$
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| Maximum value of job at any one location: |
$
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| Maximum value of material in transit at any one time: |
$
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| Maximum value of material in temp. storage at any one time: |
$
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| Equipment and Tool Coverage: |
| Total Value of tools and equipment owned $1,000 per item
or more: |
$
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| Total Value of tools and equipment owned under $1,000 per
item: |
$
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| Liability Coverage: |
| General Liability (per occurrence) |
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| Optional Coverages: |
| Non-Owned/Rental Auto Liability: |
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| Employee Dishonesty: |
| Amount |
$
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| Forgery: |
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| Loss of Income: |
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| Request for Additional Coverage |
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| COMMERCIAL AUTO LIABILITY
(Cars AND Trucks) |
| VEHICLE #1 |
| Year of Vehicle |
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| Purchase Price |
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| Limit of Liability: |
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| Deductible on Comprehensive: |
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| Deductible on Collision: |
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| VEHICLE #2 |
| Year of Vehicle |
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| Purchase Price |
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| Limit of Liability: |
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| Deductible on Comprehensive: |
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| Deductible on Collision: |
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List any trade organization in which you are
a member
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| Additional Comments
Please give any additional comments you wish about this quotation.
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