Contractors Application Form
General Business Information:
Business Name:
Owners Name
First Name
Last Name
Phone Number
Format: (000) 000-0000.
Policy Holder Email Address
Mailing Address
Street Address
Suite / Apt Number
City
State
Zip Code
Primary Business Address
Street Address
Suite / Apt Number
City
State
Zip Code
Business Type (e.g. LLC, Sole Proprietorship, Partnership, Corporation, etc.
Federal Tax ID
State ID
Describe your business operations?
How long have you been in business?
Are you licensed in the state of domicilied?
Yes
No
Do you operate in other states besides home state?
Yes
No
Operations and Locations
Where is your business located? (home, building, owned, leased, etc.)
Policy Start Date:
-
Mes
-
Día
Año
Date
Most Popular Coverages
Business Owners Policy
General Liability
Commercial Property
Professional Liability (E&O)
Cyber Liability
Directors & Officers Liability
Employment Practices Liability
Bond
Crime
Commercial Flood
Umbrella
Coverage Limits You Require
100,000
300,000
500,000
1,000,000
2,000,000
5,000,000
10,000,000
Business Details
Estimated Total Gross Revenue for Next 12 Months:
Number of Employees (excluding business owners)
Full Time Employees:
Part Time Employees:
Estimated Wages at Primary Business Address for Next 12 Months:
Business Owners Only:
Full Time, Part Time, and Temporary Employees:
1099 Contractors:
Have you had any claims or lawsuits in the past five years?
Yes
No
If so, what were the outcomes?
Has this business had a lapse of coverage, been declined, canceled, or non-renewed in the last 3 years?
Yes
No
Percentage of job locations (e.g. residential, commercial, industrial=
Percentage of Projects by Type: (e.g. new construction, renovations, repairs)
Average Project Size (Cost):
Risk and Liability Exposure
Any work performed 3 stories or higher:
Yes
No
Do you perform work involving heavy machinery, excavation, or demolition:
Yes
No
Do you perform work involving Structural Changes or High-Rise Buildings:
Yes
No
Do you require bonds for certain projects?
Yes
No
Any worked performed in New York?
Yes
No
Do you have workers compensation coverage for your employees?
Yes
No
Person Completing Application
Submit
Should be Empty: