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General Liability + Workers Compensation
Company Name
*
New Business
New Business
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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Describe your business operations. List ALL types of work performed (please be as specific as possible). Anything not listed here will not be covered.
Describe your business operations. List ALL types of work performed (please be as specific as possible). Anything not listed here will not be covered.
*
Total
*
⚠️The percentages must total 100%. Please check your entities.⚠️
*
NOT BEING USED.
Type of Work
% of work
Employee #
Employee Payroll
Subcontractor Payroll
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Do the owner(s) do the same type of work as above? Or do owner(s) only supervise or do administrative work?
*
Estimated Annual Revenue (total amount received for your services before taxes and expenses)
*
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Do you have employees, helpers, or UNINSURED subcontractors? (You can add INSURED subs on the next page)
Yes
No
How many employees, helpers, or UNINSURED subcontractors do you have?
*
How much do you pay them per year? (total payroll)
*
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Do you use INSURED subcontractors?
*
Yes
No
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
How much do you pay INSURED subcontractors per year?
*
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Are you a contractor or do you do construction work?
*
Yes
No
Do you do cleaning or janitorial services?
Yes
No
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
How much of your 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).
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Do you want a quote for General Liability?
*
Yes
No
General Liability
General Liability
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?
*
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Do you want a quote for Workers Compensation?
*
Yes
No
Workers Comp
Workers Comp
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?
*
How long has it been since you've had coverage?
*
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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