Shield Insurance Agency - Contractors Insurance Form

Contractor Business Name:
How did you hear about us?

Internet Ad Internet Search Dave Ramsey Drive-by Recommended by someone Other:
Type Here
Phone Number:
Entity type:

Individual/Sole Proprietor Partnership Corporation LLC Non- Profit Trust Limited Partnership
If not corporation: Owners full name, home address & DOB:
FEIN:
Owners Date of birth:

Month Day Year
Date
Contact name:
Contact name:
Email
example@example.com
Percent Commercial work

0% Less than 20% 20% 40% 60% 80% 100%
Percent residential work

0% Less than 20% 20% 40% 60% 80% 100%
# of New Homes/year
General Contractor?

Yes No

What percent (revenue/income) of the following do you do…. (Please try and add to 100%)

less than 20%

20%

40%

60%

80%

100%

Snowplowing

Concrete-wall

Electrical

Drywall

Interior Carpentry

Pool/SpaExterior Painting

Exterior Carpentry

Siding

Concrete-flat

Insulation

Windows

Landscaping

Heating/Cooling

Plumbing

Excavating

Roofing

Interior Painting

Year business started:
# of Years experience in this field:
# years with current carrier:
Any lapse in coverage or claims in the last 5 years for any of your policies? If yes, please describe.
Gross Annual Income:
# of Emp (full & part time):
Annual Payroll (W2+1099):
Any Subcontractors used:

Yes No
Annual Subcontractor Cost:
Do you require certificates of insurance from subcontractors w/equal liability limits:

Yes No
Business Personal Property and tools coverage amount:
Scheduled Items and Approximate Values:
Occupancy:

Lessor’s Risk Owner-Occupied Tenant Other:
Type Here
Sq Footage Occupied:
% office space

0% less than 25% 25% 50% 75% 100%
% warehouse/shop space

0% less than 25% 25% 50% 75% 100%
% That has Sprinkler

0% less than 25% 25% 50% 75% 100%
Alarm

Yes No
# of Stories total

1 2 3 4
Any Additional comments:
Only answer Questions below if you are the building owner

Questions only necessary if you are the building owner
Building Coverage Limit (if owner):
Building construction type:

Frame Joisted Masonry Non-Combustible Masonry-Non-Combustible
Please tell us the Years your wiring, roofing, plumbing and heating were last updated
Year Building Built:
Should be Empty:

Only answer Questions below if you are the building owner