New Business Insurance Quote
Contractor Intake Form
Business Name:
*
Contact Name:
*
First Name
Last Name
Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address:
Are you the owner?
Yes
No
Do you hold 100% ownership?
Yes
No
List the Name, Title, and Ownership % of all officers (must equal 100%):
Business Type:
*
Please Select
Corportation
LLC
Partnership
Individual
Trust
Other
Description of Business:
*
(Include your web address if you have one)
Number of years in business:
*
Number of years in the industry (experience):
*
CSLB Number:
FEIN:
Physical Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Physical Location same as Mailing Address?
Please Select
Yes
No
Mailing Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
When does coverage need to take effect?
*
-
Month
-
Day
Year
Do you currently have coverage in place?
*
Please Select
Yes
No
What type of coverage are you looking for?
*
Workers Compensation
General Liability
Commercial Property
Commercial Auto
Professional Liability / Errors and Omissions
Employment Practices Liability
Commercial Umbrella
Commercial Earthquake or Flood
Bond
Other
Upload Driver List and Vehicle List
Browse Files
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Choose a file
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of
Any prior claims?
*
Please Select
Yes
No
Upload 5 Years of Loss History (if available):
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of
Describe any losses here:
Revenue, Payroll and Sub-Contractor Breakdown
Estimated Annual Gross Sales
Estimated Annual Field Payrolls
Estimated Annual Sub-Contracted Costs
Do you hire sub-contractors?
Please Select
Yes
No
Estimated Annual Sub-Contracted Costs
What type of work do you sub out?
Scope of Work
% of New Construction Work (Ground-Up)
% of Remodeling
% of Residential Work
% of Commercial Work
What is the max height work you perform?
*
File Upload. (Optional)
Browse Files
Drag and drop files here
Choose a file
**Please upload anything that will help us quote your business. Examples include Declaration Pages, Insurance Requirements, etc.
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of
Any notes for our team? (Optional)
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