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General Liability + Workers Compensation
Company Name
*
Legal Entity Type
*
LLC
Partnership
Corporation
Individual/Sole Proprietorship
Business Start Year
*
EIN
*
Street Address
*
City
*
State
*
Zip
*
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Owner Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Years of experience in this industry
*
Is there another owner?
Yes
No
Owner Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Years of experience in this industry
*
Estimated Annual Revenue
*
Do you have employees?
Yes
No
How many employees do you have?
*
How much do you pay them per year? (total payroll)
*
Do you use insured subcontractors and keep copies of COI?
Yes
No
How much do you pay them per year?
*
Describe your business operations
*
Do you do construction work?
*
Yes
No
How much of your work is residential and how much is commercial?
*
Residential
Commercial
How much of your work is new construction vs. remodeling?
*
New Construction
Remodeling
Do you do framing? By framing we mean building the structure of the home, see picture below.
*
Yes
No
What % of your work is framing?
*
Do you do roofing?
*
Yes
No
What % of your work is roofing?
*
Do you do painting?
*
Yes
No
What % is exterior vs interior?
*
Exterior
Interior
Do you do flooring?
*
Yes
No
What types of flooring?
*
Tile, Ceramic
Hardwood
Carpet, Laminate, LVP
Do you do cleaning/janitorial services?
*
Yes
No
How much of your work is residential (houses) and how much is commercial (offices, post construction clean up)?
*
Residential
Commercial
Do you want a quote for General Liability?
*
Yes
No
Describe your current coverage status
*
I currently have general liability insurance
I had coverage but it was cancelled/expired
I have never had general liability insurance
What is the expiration date of your current policy?
*
How long has it been since you've had coverage?
*
Do you want a quote for Workers Compensation?
*
Yes
No
Describe your current coverage status
*
I currently have Workers Compensation insurance
I had coverage but it was cancelled/expired
I have never had Workers Compensation insurance
What is the expiration date of your current policy?
*
Since you have no employees, do you want a "ghost policy" (minimum coverage, only used to send proof of insurance) or coverage for yourself as the owner? *Coverage for the owner is more expensive.
Minimum coverage
Coverage for owner
How much do you pay yourself as the owner?
How long has it been since you've had coverage?
*
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