Language
English (US)
Portuguese (Brazil)
Spanish (Latin America)
General Liability + Workers Compensation
Company Name
*
Legal Entity Type
*
LLC
Partnership
Corporation
Individual/Sole Proprietorship
Business Start Year
*
EIN
*
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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
*
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Estimated Annual Revenue/Gross Sales
*
This is the TOTAL amount received for your services before taxes and expenses.
List ALL types of work performed separately. Additionally, add the estimated employee/subcontractor payroll for each type of work.
Type of Work
% of work
Employee Payroll
Subcontractor Payroll
1
2
3
4
5
6
7
8
9
10
Total % of Work
*
⚠️The percentages must total 100%. Please check your entities.⚠️
*
Total Employee Payroll
*
How many employees/helpers do you have?
*
Total Subcontractor Payroll
*
Do all subcontractors provide you a Certificate of Insurance (COI), with your company name listed as the Certificate Holder? If not, GO BACK to the previous page and add them as UNINSURED subcontractors.
*
Yes, I keep copies of COI
Do the owner(s) do the same type of work as above? Or do owner(s) only supervise or do administrative work?
*
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Are you a contractor or do you do construction work?
*
Yes
No
How much of this work is residential (homes) and how much is commercial (buildings, apartments)?
*
Residential
Commercial
How much of your work is new construction (building has not been occupied) vs. remodeling (adding to or changing and existing building)?
*
New Construction
Remodeling
Are you involved in any new residential construction in communities where they are building more than 10 homes at one location? This does not include custom homes. or any work done directly for the homeowner. Many carriers exclude work on new construction homes, so if you do this we'll make sure to find a policy that covers you for this type of work.
Yes
No
What % is exterior vs interior?
*
Exterior
Interior
Is any exterior work done above more than 15 feet above ground?
*
Yes
No
Explain what types of tools you use (ex ladders, etc), and any protective measures you take to prevent injury (ex. harness, helmet, etc).
Do you do cleaning or janitorial services? This does NOT include cleaning up your own work.
Yes
No
How much of this work is residential (homes) and how much is commercial (buildings, apartments)?
*
Residential
Commercial
Do you clean up construction debris from new construction homes? (This does not include cleaning up debris after renovations to existing homes) Many carriers exclude work on new construction homes, so if you do this we'll make sure to find a policy that covers you for this type of work.
Yes
No
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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/was the expiration date of your current/prior policy?
*
What insurance carrier?
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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/was the expiration date of your current/prior policy?
*
What insurance carrier?
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/Ghost Policy
Coverage for owner
How much do you pay yourself as the owner?
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Are you working for any specific contractors or already have a sample of the insurance requirements?
Please upload any documents that may help us quote (sample COI, identification, prior coverage, etc.)
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