Property
Auto


Contractor Insurance Quote Form

For California residents only

Your Name

D.B.A.

Email


(important if you'd like to receive your quote via email)

Address

City

State

CALIFORNIA

Zip

Home phone

Work phone

Fax

License held:

License number:

No. of years business entity has operated under current name:

No. of total years experience current management has in this type of contracting business:

Receipts derived from work as: General Contractor %
Artisan or Subcontractor %
Percent of work which is: Residential % Commercial %
Type of work you do: Ground up construction %
Remodelling %Additions %
Renovation/Redecorating %
Repair/Maintenance %
Current number of owners/partners/officers:

Current number of employees:

Current year est. annual payroll (excluding owners): $
Current year est. annual total costs Subbed: $
Type of work subbed:

Total estimated annual receipts: $
During the past 5 years have you ever been involved in the original structural construction or remodelling of:
Townhouses Yes NoCondominiums Yes No
Row houses Yes NoTracts or developments Yes No
Do you anticipate getting into any of this type of work? Yes No

If yes, please explain:

Have you been involved with operations involving construction of load-bearing walls, structural support, foundations, slab floors or retaining walls, now or at any time? Yes No
Do you anticipate getting into any of this type of work? Yes No

If yes, please explain:



Do you require all subcontractors to name you as an additional insured on their General Liability policy? Yes No

Do you require certificates of insurance evidencing a minimum of $500,000 of General Liability from subcontractors? Yes No

Do you rent or lease equipment to others? Yes No

Do you use standard construction industry contracts? Yes No
Have you ever been sued? Yes No
If yes, please give a brief description of suit and outcome:

Current insurance carrier:



Expiration date:



Losses in past 5 years:

Yes No

If yes, please give a brief description of loss and outcome:

General Liability limits requested:

Additional remarks:

How would you like to receive your Contractor Insurance Quote?

Call me
 U.S.Postal
Email
Fax

 
   



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