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
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Contact Person Details:
Contact person's full name
*
First Name
Last Name
Contact person's phone no.
*
Please enter a valid phone number.
Contact person's email
*
example@example.com
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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.
*
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Business Risk Assessment:
Business start date
*
-
Month
-
Day
Year
Date
No. of years of related prior experience
*
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.
*
Operation
%
1
2
3
4
5
6
7
8
9
10
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
Owner
Lessee
Tenant
2
Owner
Lessee
Tenant
3
Owner
Lessee
Tenant
4
Owner
Lessee
Tenant
5
Owner
Lessee
Tenant
6
Owner
Lessee
Tenant
7
Owner
Lessee
Tenant
8
Owner
Lessee
Tenant
9
Owner
Lessee
Tenant
10
Owner
Lessee
Tenant
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
Have you been involved in wrap-up policies in the past five years?
*
Yes
No
If “Yes”, please provide full details.
*
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Business Risk Assessment continued ............
What is the breakdown for work performed by you or on behalf of you? (Enter 0 if does not apply to you)
*
Commercial
Industrial
Residential
New Construction
Renovation
% of Revenue
In what territories do you conduct operations:
*
Canada
US
Other
Do you request proof of insurance from subcontractors?
*
Yes
No
If “Yes”, indicate the limit of liability required: $
*
Do you engage in any of the following operations?
*
Demolition or Wrecking
Raising or Moving
Excavation
Use of Explosives
Welding (off premises)
Testing of Equipment i.e. gas connection, pressure vessels
Caisson Work
Shoring
Tunnelling
Underpinning
Bridge/Dam
Radioactive Isotopes
Asbestos Removal
Lead Abatement
Handling of PCBs
Tank Remediation
Mould Abatement
Mould Prevention Treatment
None of the above (Enter "N/A" in the details section)
If you checked any of the above operations, please provide full details of work undertaken.
*
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Business Risk Assessment continued ............
Do you perform work in any one of the following?
*
Medical
Aerospace
Airport
Oil and Gas
Railroad
Scientific
Nuclear
None of the above (Enter "N/A" in the details section)
If you checked any of the above operations, please provide full details of work undertaken.
*
What are the safety measures taken to protect the public on and off site?
*
Do you rent or lease mechanical equipment to or from others?
*
No
Yes, with Operator
Yes, without Operator
Are you bonded by a “contract surety” company?
*
Yes
No
How are waste materials disposed of? Please fill up as many rows as needed.
*
Waste Material
Disposition details .............................
1
2
3
4
5
6
7
8
9
10
Have you signed any contracts containing “hold harmless” clauses in favour of others?
*
Yes (You will be required to provide the copies of agreement)
No
By submitting the above-mentioned information, the applicant declares that all statements made in the questionnaire and the information contained in documents submitted with it are true. Submitting of this document does not bind the applicant to complete the insurance, but it is agreed that the questionnaire shall be the basis of the contract, should a policy be issued.
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Should be Empty: