CONTRACTOR INSURANCE

CONTRACTOR INSURANCE FORM


Type of Business :	Sole Proprietor Corporation Partnership LLC
Contractor Type :	Dry Wall Electrician Painter Plumber Roofer General
Business Name :
Contact Person :
Phone Number :	(xxx-xxx-xxxx)
EmailAddress :
Address :
City :
State :
Zip :
Fax Number :	(xxx-xxx-xxxx)
Years in Business :
Claims in last three years :	Yes No
If Yes, list claims details :
Number of Employee :
Total Payroll :	$
Bankruptcies or Tax Leins in past 5 years :	YesNo
Policy Effetive Date :
Policy Renewal Date :
Number of Vehicles to Insure :
Approximate Current Premium :
Current Insurance Carrier :
Estimated Gross Sales :	$
Do You Sub Out Work :	Yes No
If Yes, what percentage do you sub out :	%
Percentage of Commercial Business :	%
Percentage of Residential Business :	%
New Construction Work :	%
Remodeling Work :	%
Repair Work :	%
Do you want tool coverage :	Yes No
If Yes, what amount of coverage::	$
Amount of Coverage Requested :	$300,000 $500,000 $1,000,000
Do you rent equipment on a regular basis :	Yes No
Do you need a bond? :	Yes No