General Liability Quote
Fields marked (*) are mandatory.
General Information
Name of Business*
Inspection Contact Name*
Mailing Address*
City*
State*
Zip*
Location Address*
City*
State*
Zip*
Business Phone
Fax
Contact Email Address
Business Status
Years in Business
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
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
Sub contracted Out (%)
Sub Costs ($)
Do you collect certificates of insurance at a $1,000,000 limit?
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 and clerical ($)
Dollar value of average job completed incl. all
materials, lab and/or equipment ($)
Describe any projects (underway or planned) for
the next year, including values
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?
Have you ever been named in litigation regarding
faulty construction?
Are there any claims or legal actions pending?
Do any of the entities named in the application
have knowledge of any pre-eisting act, omission,
event, condition or damages to any person or
property?
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:
Date of Occurrence
Date of Claim
Type/Description of Occurrence or Claim
Amount paid on your behalf
Amount reserved on behalf
Claim #2
Claim Status
Date of Occurrence
Date of Claim
Type/Description of Occurrence or Claim
Amount paid on your behalf
Amount reserved on behalf
Additional Comments
Please give any additional comments you feel appropriate for this quotation.