Contractors Insurance Quote Form

Personal Information
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender
Marital Status
Occupation / Work Information
Driver License

Business Details
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Years In Business
Annual Revenue
Number of Employees
Business Status
If Other, Please Specify
Coverage Needs
Business Liability Limits
If Other, Please specify

Building / Business Personal Property
Interest
Building Limit
Business Personal Property Limit
Property Deductible Type
Property Deductible
Wind/Hail Deductible
Year Built
Construction Type
Percent Sprinklered
Total Square Footage
Number of Stories
Number of Elevators
Basement
Roof
Year Roof Built
Roof Valuation
Prior Unrepaired Roof Losses
Have You Operated Business In Any other Name?
If Yes, Please Provide Business Name
Breakdown of Work (How many percent)
List States in which you work in or plan to work in:*
What is the maximum number of projects under the course of construction at any one time?
What is your radius of operations? (In Miles)
Do you offer design or Engineering Services?
If yes, please describe
Do you act as Property Manager?
If yes, how much is spent annually to rent equipment?
Do you have a formal fleet safety program in place?
Do you Subcontract Work to others?
If yes, what is the percentage of work subcontracted work and describe what is being subcontracted?
Do you have a written subcontractor agreement?
If Yes, Please upload a copy of the agreement
Do you have an equipment maintenance program in place?
Is all equipment secured at the jobsite when not in use?
Is any equipment transported to and from jobsites?
If yes, please explain
Does the insured lease, rent, or borrow equipment from others?
Type Of Contractor

Carpentry Contractors Questionaire
Identify any specialized services the contractor performs (Percentage)
Does the insured have a cabinet or woodworking shop?
If yes, select in any of the following
Any lead abatement?
Does insured do any work with asbestos?
Does insured do any EIFS (Exterior Insulation & Finish Systems) work?
Type a question
Does insured do any mold remediation work?
What were the number of jobs you had last year for?
Do you have any other Contractor Business?
Select the other Contractor Business

Concrete Contractors Questionnaire
Type of Work Performed (How many percentage)
Is scaffolding used?
Is there any installation of precast (like spancrete/concrete plank)?
Is there any installation of precast ‘tip up’ walls?
Does insured do any repair of existing foundation?
Does insured do tuck-pointing?
Type of municipal work: (How Many Percentage)
Is concrete waterproofing performed?
If yes, how is it applied?
Does insured perform excavation/backfilling work?
Are all changes to architectural plans signed off and agreed to by customer?
Do you have any other Contractor Business?
Select the other Contractor Business

Electrical Contractors Questionnaire
Type of Work Performed (How Many Percentage)
Identify any specialized areas where contractor performs work (Hoe many Percentage)
If Other Types of Wiring, please describe
Does the insured attach COPALUM or Alumi Conn connectors to aluminum wiring?
Does the insured sell, service or install Standard Pacific, or Stab Loc panels, and breakers?
Does insured install underground cable?
If yes, What equipment is used?
Does insured install, or work with, outdoor above ground pole wiring?
Does insured install transformers?
Does the insured install roadway lighting, or electrical signals?
Does the insured offer any thermography services?
Does the insured do any arc flash assessments or training?
Does the insured do any electrical work for machine guarding on industrial machining?
Do you have any other Contractor Business?
Select the other Contractor Business

Excavation Contractors Questionnaire
Type of Work Performed (How many percentage)
Describe other work
What is the maximum depth excavated? (In Feet)
Are trench boxes used?
Are utilities staked before the start of every dig?
If telephone inquiries are made, is a log maintained containing the date, time person spoken to, plot number referred to?
If no, please explain
Does the insured haul dirt, sand, or gravel for hire?
If yes, how many percent
Is blasting work contracted out?
If yes, how many percent
Cost
Is any demolition work done?
If yes, how many percent
Please describe
Any demolition work above 2 stories?
Does the insured do any work at landfill sites?
Does the insured remove, dig, handle or haul contaminated soil?
Does the insured perform any brownfield work?
Does insured do any work on bridges or dams?
Any work with mines?
If yes, please explain:
Does the insured to any horizontal boring?
Do you have any other Contractor Business?
Select the other Contractor Business

Floor Covering Installation Contractors Questionnaire
Type of Work Performed (How many percentage)
Please describe
Does insured do work with epoxy floor covering?
Does the insured do any work with asbestos?
If yes, please describe:
Is the insured involved in any retail sales of flooring materials?
Do you have any other Contractor Business?
Select the other Contractor Business

General Contractors Questionnaire
Type of Work Performed (How Many Percentage)
Do you always maintain a job site presence through Executive Supervisors, who regularly visit all job sites?
Do you always maintain a job site presence through employees doing trade work at the job site?
Does your work/subcontracted work include any of the following (check and explain all that apply on the remarks section below):
Do you own or manage rental properties?
Remarks:
Do you have any other Contractor Business?
Select the other Contractor Business

Glass Dealers and Glaziers Contractors Questionnaire
Type of Work Performed (How many percentage)
Any work performed over two stories?
If yes, please describe
Any stain glass work performed?
If yes, please describe
Do you provide 24-hour emergency services?
Do you manufacturer bullet proof glass?
If yes, please describe
Do you have any other Contractor Business?
Select the other Contractor Business

Heating and Air Conditioning Contractors Questionnaire
Type of Work Performed
Does insured do any LP gas installation?
Percentage of operations
Does insured install industrial ovens/drying systems?
Does insured install heated industrial return air systems?
Does insured install industrial ventilating/exhaust systems?
Does insured install commercial chillers?
Does insured perform any maintenance on commercial refrigeration coolers?
Is any boiler work performed?
If yes, please describe:
Any roof top units installed?
Is a crane operator rented?
Does insured perform any Freon recapture services?
Does insured fabricate any commercial ductwork or process piping?
If yes, please describe:
Do you have any other Contractor Business?
Select the other Contractor Business

Insulation Contractors Questionnaire
Type of Work Performed
Select the following types of insulation insured uses
Describe other types used by insured
Are all types of insulation used ‘approved’ by a credited testing laboratory?
Does the applicant sell/install any insulation under own name or label?
If yes, please describe:
Does insured now or have they ever installed/removed asbestos insulation?
If yes, describe largest jobs
Does insured currently or have they ever-installed foam or sprayed –on plastic insulation?
If yes, describe largest jobs
Does insured do any EIFS (Exterior Insulation & Finish Systems) work?
Does insured do any mold remediation work?
Does insured use or install imported drywall?
Do you have any other Contractor Business?
Select the other Contractor Business

Janitorial Contractors Questionnaire
Type of Work Performed (How Many Percentage)
Toluene Used?
Outside Maintenance Work (How many percent)
What type
Window Cleaning? (How many percent)
How many stories?
Medical Office Work (How many percent)
What type?
Water/Fire Restoration (How many percent)
Do you offer security services to your customers?
If yes, please describe
What is the average crew size?
Supervisor at job locations at all times?
If no, please explain:
Does the insured sell any private label products?
Does the insured do any herbicide or pesticide work?
If yes, please describe:
Does the insured do any pest control or extermination work?
If yes, please describe:
Does the insured do any janitorial work on aircraft?
If yes, please describe
Is any demolition work done?
If yes, please describe:
Does the insured do any mold remediation work?
If yes, please explain
Does the insured use or install imported drywall?
If yes, please provide details:
Do you have any other Contractor Business?
Select the other Contractor Business

Landscaping Contractors Questionnaire
Type of Work Performed
For tree trimming and removal, can you provide how high is it?
Other, please describe:
Any installation of underground sprinkler systems?
Any installation of retaining walls or hardscaping?
Are herbicides or pesticides applied?
If yes, percentage of sales:
If yes, please describe:
Do you have any other Contractor Business?
Select the other Contractor Business

Masonry Contractors Questionnaire
Type of Work Performed
Is any work over one story?
If Yes - Maximum height worked at?
If Yes -Is scaffolding used?
If Yes -Is swing stage used?
Does insured install masonry fireplaces construction work?
Receipts
Does insured do separate waterproofing work?
If yes, how applied?
Does the insured do any repair of existing foundations?
Receipts
Does insured perform tuck-pointing?
Receipts
Does insured do any EIFS (Exterior Insulation & Finish Systems) work?
Do you have any other Contractor Business?
Select the other Contractor Business

Painting Contractors Questionnaire
Type of Work Performed (How Many Percentage)
Method of Application
Highest number of stories worked?
Does insured use their own scaffolding?
Choose in the following if you do any specialized work
Does insured work from swing stages or bosun chairs?
If Yes, please explain
Does insured offer any drywall finishing services?
If yes, please provide details
Do you have any other Contractor Business?
Select the other Contractor Business

Plumbing Contractors Questionnaire
Type of Work Performed (How many percentage)
Does the insured install pump systems?
Does insured install septic/mound systems?
Does insured install septic/mound systems?
Is any high pressure boiler work performed?
Any boiler work >20PSI done?
Does insured have a Cross Connection License?
a. If yes, how much of his operation involves backflow preventor work?
b. Does the insured install/repair sprinkler systems or automatic extinguishing systems?
If yes, please provide details:
Does the insured do any Process Piping work?
If yes, please provide details:
Does insured perform any ammonia services?
Do you have any other Contractor Business?
Select the other Contractor Business

Roofing Contractors Questionnaire
Type of Work Performed (How many percentage)
Any work above 2 stories?
If yes, what percentage?
Are written procedures in place to assure that an opening in the roof will never be left unattended and will be properly covered and anchored before living a jobsite?
If no, please explain
Is hot tar used?
If yes, what size are the kettles and is tar heated before traveling to a job site or upon arrival?
What percent of work involves using hot tar?
Are torches used?
If yes, please explain the processes and safety precautions used to prevent fires during and after work hours:
Do you have any other Contractor Business?
Select the other Contractor Business

Siding Contractors Questionnair
Is any work performed over one story?
If yes, how high?
Is scaffolding used?
If yes, does the firm erect and maintain the scaffolding or is it contracted out?
Does the insured do any roofing?
If yes, how many percent
Does the insured do any insulation work?
If yes, how many percent
Please describe:
Does the insured install any stucco siding?
Does insured do any work with asbestos?
Any torches and/or hot air welders used?
If yes, please explain the processes and safety precautions sued to prevent fires during and after work hours
Do you have any other Contractor Business?
Select the other Contractor Business

Street and Road Construction Contractors Questionnaire
Type of Work Performed
Do you perform excavation/backfilling work?
Do you perform striping/marking?
Do you own a pit or quarry to supply aggregate needed for paving?
Is work performed along busy highways?
Do you employ your own flaggers?
If yes, are they certified in traffic control by a state- approved agency?
Describe traffic control measures at jobsites:
Are worksites easily identified by signs, cones, barrels and barricades?
Are all pavers and dump trucks equipped with backup alarms?
Do you perform any design work?
Do you have any other Contractor Business?
Select the other Contractor Business

Optional Coverage
Choose Optional Covergae*
Damage to Premises Rented to You
Voluntary Property Damage - Bis-Pak
Occurrence/Aggregate

Additional Information
Current Insurance Provider
Preferred Payment Option
Policy Effective Date

MonthDayYear
Date
RMBIA Service Rep Fill out this form?
Have you read the T&C?
Additonal Notes or Comments
Upload Photos, Files, or Documents Here

Cancelof
Please verify that you are human*
By submitting, I acknowledge that I am requesting an insurance quote and authorize RMB Insurance Agency to obtain my credit and loss history reports.
Should be Empty:

Personal Information

Business Details

Building / Business Personal Property

Carpentry Contractors Questionaire

Concrete Contractors Questionnaire

Electrical Contractors Questionnaire

Excavation Contractors Questionnaire

Floor Covering Installation Contractors Questionnaire

General Contractors Questionnaire

Glass Dealers and Glaziers Contractors Questionnaire

Heating and Air Conditioning Contractors Questionnaire

Insulation Contractors Questionnaire

Janitorial Contractors Questionnaire

Landscaping Contractors Questionnaire

Masonry Contractors Questionnaire

Painting Contractors Questionnaire

Plumbing Contractors Questionnaire

Roofing Contractors Questionnaire

Siding Contractors Questionnair

Street and Road Construction Contractors Questionnaire

Optional Coverage

Additional Information