On-Line Contractors Liability Quote Form
One Simple Form - takes only 2-3
Minutes!
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| Your
Name: |
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| BUSINESS
Name: |
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| Mailing
Address: |
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| City:
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| Province:
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| Postal:
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| E-Mail
(REQUIRED): |
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| Phone:
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| Fax
(optional): |
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| Business Underwriting Information |
| Type
of operation: |
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| Describe
operations in detail: |
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| License
class: |
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| License
Number: |
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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
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| Currently
Insured? |
Yes
No |
| Name
of Carrier & how long insured? |
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| Prior
Claims? |
Yes
No |
| Describe
claims in detail: |
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| Years
in business: |
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| Years
experience in field: |
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| Percentage
of work residential: |
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| Percentage
of work commercial: |
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| Number
of Active Owners: |
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| Number
of Employees: |
0
1
2
3+ |
| Annual
Employee Payroll: $ |
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| Annual
Gross Sales: $ |
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| Do
you subcontract work? |
Yes
No |
(If
yes, what percentage of your work
is subbed, and what kind of work?) |
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| 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
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| Comments/Remarks: |
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