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Owner's Name
*
Business Entity / DBA
Phone
*
Email
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What date do you need your policy by?
*
MM slash DD slash YYYY
Would you like a quote for...
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Type of Insurance *
Auto Insurance
Builder's Risk Insurance
Contractor's General Liability Insurance
Homeowners Insurance
Workers' Compensation Insurance
Life Insurance
Other
Business Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
FEIN #
Number of Years in Business
*
Type of Work Performed
*
Air Conditioning
Appliance Installation
Cabinet Installers
Carpentry
Carpet-Upholstery Cleaning
Ceiling/Wall Installation - Metal
Communication Equipment Installation
Concrete Construction
Conduit Construction - Cable/Wire
Debris Removal - Construction Site
Door/Millwork Installation - Metal
Drilling - Water
Driveway/Sidewalk Paving
Drywall
Electrical
Excavation
Exterminators
Fence Erection
Flooring
Framing
General Contractor
Grading
Handyman
Heat/AC no LPG
House Furnishings Installation
HVAC Contractors
Interior Decorators
Janitorial - Residential
Janitorial - Commercial
Landscaping Gardening
Masonry
Metal Erection - Decorative
Painting
Paperhanging
Piano Tuners
Plastering or Stucco Work
Plumbing
Power Spray
Prefabricated Building Erection
Professional Organizers
Refrigeration Equipment Installation/Service
Roofer
Satellite Dish Installation
Scaffolding
Septic Tank
Sewer Mains Construction
Siding and Gutter Installation
Snowplow
Stonework
Tile/Stone Installation
Tree Surgeons
Waterproofing
Water Mains Construction
Windows and Door Installation
Projected Annual Gross Sales
Number of Employees
*
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0
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Annual Employee Payroll
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0
.
Annual Subcontracting Costs
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0
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Annual Material Costs
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0
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Percentage (%) of Residential Work
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50%
60%
70%
80%
90%
100%
Percentage (%) of Commercial Work
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10%
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50%
60%
70%
80%
90%
100%
Percentage (%) of New Construction
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40%
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60%
70%
80%
90%
100%
Percentage (%) of Remodels/Renovations/Service Work
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10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Percentage (%) of Interior Work
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10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Percentage (%) of Exterior Work
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70%
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100%
Full Address
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Date of Birth
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Auto Details:
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Drivers License:
Car Year:
Car Make:
Car Model:
VIN #:
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Use of the car(s):
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Commute
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Coverage
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Marital Status:
*
Single
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Spouse's Name
*
Spouse's Date of Birth
*
MM slash DD slash YYYY
Spouse's Drivers License #
*
Project Site Full Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Start Date/Policy Effective Date:
*
MM slash DD slash YYYY
Estimated Completion Date:
*
MM slash DD slash YYYY
Type of building:
*
Brick
Frame
Square footage of building/structure:
*
How Many Stories:
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Completed Value of Property:
*
Policy period required for insurance:
*
3 months
6 months
9 months
12 months
Deductible (Minimum $1,000 max $10,000):
*
Please enter a number from
1000
to
10000
.
General Liability needed (100/300/500/1)?
*
Yes
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Has any work started?
*
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Date of Birth
*
MM slash DD slash YYYY
Full Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Time living in Address:
*
Current insurance company:
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Years w/ Prior Carrier:
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Dogs on the premises?
Yes
No
Feet From Hydrant:
*
Distance From Fire Station (miles):
*
Mortgage company:
*
Value of Home:
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Current Deductible:
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Type of building:
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Brick
Frame
Square Footage:
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Year built:
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