Personal Information
*First Name
*Last Name
Business Name DBA
Business Address
City/St/Zip
*Phone Number
Alternate Number
*Email Address
Underwriting Information
What is the nature of your business?
Is the business a corporation, partnership, or sole proprietorship?
Corporation Partnership Sole Proprietorship
Number of owners
Number of Employees
Payroll of Owners
Payroll of Employees
Total annual gross receipts
Business License Number
License Type
Years of experience
Years operated under current name
Other business names?
Yes No
If yes, what other names?
Have you been involved in the original construction or remodeling of town homes, condos, row homes or developments of 15 or more unattached single family dwellings during the past 5 years?
Yes No
Do you construct footings or foundations which may support dwellings or other structures?
Yes No
Do you construct slab or monolithic floors?
Yes No
Do you construct piers or underpinning which may support dwellings or other structures?
Yes No
Do you construct retaining walls which may support dwellings or other structures?
Yes No
Do you construct fireplaces or chimneys?
Yes No
What is the percentage of work done as a General Contractor?
What is the percentage of work done as a Sub-Contractor?
What is the percentage of work done on Residential?
What is the percentage of work done on Residential?
What is the percentage of work done on Commercial?
What is the percentage of work done for Remodeling?
What is the percentage of work done for Renovation?
What is the percentage of work done for Repair or Maintenance?
Claims Information
Were there any losses or claims in the last 5 years?
Yes No
If yes, what is the date, amount paid and description of each loss or claim?
Coverage Information
Current Insurance Company
How much are you paying now?
What is the liability limit requested?
-Select- 100,000 300,000 500,000 1,000,000
What is the building limit requested?
What is the building deductible requested?
-Select- 250 500 1,000 2,500
What is the business personal property (contents) limit requested?
What is the contents deductible requested?
-Select- 250 500 1,000 2,500
What is the loss of income requested??
Questions or Comments
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