Shield Insurance Agency - Contractors Insurance Form

Contractor Business Name:
How did you hear about us?

Internet AdInternet SearchDave RamseyDrive-byRecommended by someoneOther:
Type Here
Phone Number:
Entity type:

Individual/Sole ProprietorPartnershipCorporationLLCNon- ProfitTrustLimited Partnership
If not corporation: Owners full name, home address & DOB:
FEIN:
Owners Date of birth:

MonthDayYear
Date
Contact name:
Contact name:
Email:*
example@example.com
Business Address:
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?

YesNo

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

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:

YesNo
Annual Subcontractor Cost:
Do you require certificates of insurance from subcontractors w/equal liability limits:

YesNo
Business Personal Property and tools coverage amount:
Scheduled Items and Approximate Values:
Occupancy:

Lessor’s RiskOwner-OccupiedTenantOther:
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

YesNo
# of Stories total

1234
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:

FrameJoisted MasonryNon-CombustibleMasonry-Non-Combustible
Please tell us the Years your wiring, roofing, plumbing and heating were last updated
Year Building Built:
Browse Files

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Which agent would you prefer?
Please verify that you are human*
Should be Empty:

Only answer Questions below if you are the building owner