HIFA - Contractor's Insurance Quote Request

Contractor's Insurance Quote Request
Business Details:
Legal name *
Operating name (if any)
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Main phone *
Please enter a valid phone number.
Main email *
example@example.com
Website
Legal entity: *

Sole proprietorship Partnership/Joint venture Incorporation Other

Insurance Details:
Current insurance company name (if applicable)
Current insurance policy number (if applicable)
Effective/renewal date *

Month Day Year
If renewal was not being offered, please explain.
Describe all claims, including any outstanding, and fees for the last five years including any accidents, facts, circumstances or allegations which may give rise to a claim:
What action has been taken to eliminate future accidents?
Has any similar insurance applied for or carried by the Applicant been declined or cancelled by any insurer within the last three years? *

Yes No
If “Yes”, please provide full details. *

Please provide the following as accurate as possible: (Enter 0 for the past year if it is your first year) *

	Payroll	Revenue	Work Sublet
a) Past year
b) Next year estimate

Are company owners, executive officers or other office employees covered under Worker’s Compensation? *

Yes No

Please provide list of all operations performed and the breakdown for operation to the total revenue. Please fill up as many rows as needed. *

Location of all of premises, operations, also indicate Owner; Lessee; Tenant. Please fill up as many rows as needed. *

	Operation performed	Location Address including Postal Code	O/L/T
1
2
3
4
5
6
7
8
9
10

Please list and describe all contracts over $100,000 in the past year. Please fill up as many rows as needed. *

	Details of all contracts over $100,000 in the past year.
1
2
3
4
5
6
7
8
9
10

Now create your own Jotform - It's free! Create your own Jotform

Contractor's Insurance Quote Request