Current Insurance Information
Company Name (not agency):	Premium: $
Effective Date:	Expiration Date:
Please List Any Other Previous Carriers Over the Past 3 Years Below:
Carrier Name:	Premium: $
Carrier Name:	Premium: $

Project/Work Information
Please write a Description of Operations below:
What percentage of your work is:  (each line must total 100%)	Commercial  %  Industrial  %   Residential  %
	New Construction  % Remodel/Additions  %
What percentage of your work is as a:	General Contractor:  % Subcontractor:  %
What percentage of your work is:	Subcontracted Out:  % Sub Costs: $
Do you collect certificates of insurance at a $1,000,000 limit?:	Yes     No

Receipts / Payroll / Dollar Value Info
Gross receipts for the past 3 years:  and the next 12 months:	(3rd yr prior) $     (2nd yr prior) $ (Last 12 mths) $ (Next 12 mths) $
Number of owners/officers/partners active at the job site or supervising:
Payroll of employees excluding owners, officers, partners & clerical:	$
Dollar value of average job completed incl. all materials, labor & equipment:	$
Describe any project(s) underway or planned for the next year, including values below:

Miscellaneous and Legal Info
Have you ever performed ground up construction involving condominiums, townhouses, apartments, or single family tract developments of two (2) or more?:	Yes    No
Have you ever been named in litigation regarding faulty construction?:	Yes    No
Are there any claims or legal actions pending?:	Yes    No
Do any of the entities named in the application have knowledge of any pre-existing act, omission, event, condition or damages to any person or property that may potentially give rise to any future claim or legal action against any such entity?:	Yes    No

 

Claims History Enter all claims or occurrences that may give rise to claims for the prior 3 years. This information is kept strictly confidential

Claim #1	Claim Status: Closed   Open
Date of Occurrence:	Date of Claim:
Type/Description of Occurence or Claim:
Amount paid on your behalf:	$   Amount reserved on behalf: $

Claim #2	Claim Status: Closed   Open
Date of Occurrence:	Date of Claim:
Type/Description of Occurence or Claim:
Amount paid on your behalf:	$   Amount reserved on behalf: $

 

Additional Comments

Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough space, please enter them here.