Contractor Name
Contractor Main Address/Location
Contractor Phone
Contractor Website
CEO Name
CEO Email
CEO Cell
CFO Name
CFO Email
CFO Cell
COO Name
COO Email
COO Cell
Safety Name
Safety Email
Safety Cell
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Agent/Broker Name
Broker Cell
Broker Email
Incumbent Broker Status
Please Select
Incumbent Broker
Not Incumbent Broker
Current Policy Expiration Date
-
Month
-
Day
Year
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What industry group(s) best describes you?
Heavy Civil
Industrial
General Building
Are you privately owned?
Please Select
Yes
No
Any foreign ownership?
Please Select
Yes
No
States of operation and percentages (generally)
Estimated Annual Receipts
Percentage of Subcontracted Work
Estimated Annual WC Payroll
Estimated Annual Workforce Hours
Net Worth
estimated premiums (workers comp, auto liability, and general liability) before deductibles (e.g., first-dollar)
Were you referred by a member? Who?
How did you find out about ACIG?
Submit Initial Contact Form
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