contractors insurance – contractor liability insurance

Limits of Liability Desired

Company Name:

Owners Name

Contractor License Type:

Contractor License Number(s)

Years of Experience:

Years in Business

Type of Business:

Number of active Current Owners/Partners/Officers

Address:

City:

Telephone

State, Zip:

Fax:

Gross Receipts Including Labor & Material & Cost of Sub:

Average value of projects:

Number of jobs running at same time:

Payroll excluding owners, officers and clerical, but Including leased Labor:

Number of full time field employees:

Number of part time field employees:

Indicate percentage of work performed
(Total should equal 100%):

In What Capacity Do You Operate?
(Total should equal 100%):

The reason applying for insurance and additional Comments:

Will you use subcontractors?

Yes No

If yes, annual cost of sub including labor and material:

If yes, list trades of subcontractors used:

Are you or will you be involved in new ground up construction?

Yes No

Describe your involvement in new ground up construction if any:

Indicate percentage of work performed:
(Total should equal 100%)

	% Commercial
	% Residential (Single Homes)
	% Residential (Townhomes, Apts, Condos)
	% Other

Prior and/or current insurance info:

Are you currently insured?

Yes No

If yes, who is your current carrier?

Policy expiration date:

If no insurance, years without coverage:

Any claims in last 5 years?