Contractors Insurance Quote Form

Page Insurance, Ltd

102 Boston Street

Guilford, CT 06437

(203) 453-5258

info@pageins.com

Effective Date of Coverage

Date

How is the business structures?

Business Name:

Doing Business as a different name?

YesNo

Doing Business as Name:

Mailing Address

Street Address

Street Address Line 2

CityState

Zip Code

Is Location Address the same as Mailing Address

YesNo

Location Address

Street Address

Street Address Line 2

CityState

Zip Code

Applicant / Contact Name

First NameLast Name

Date of Birth

Date

Phone Number

Area CodePhone Number

E-mail

Website Address

Provide details of all your operations

Do any of the following apply?

* Is the total insured value (building + contents) of the entire policy over $1 million?&#13;&#10;* Does payroll exceed $300,000 (excluding the owner)?&#13;&#10;* Do subcontracting costs exceed 25% of annual sales?&#13;&#10;* Does any work require a crane or exceed three stories in height?&#13;&#10;* Are foundation or structural repairs performed?&#13;&#10;* Is any waterproofing or remediation work (mold / water / fire) performed?&#13;&#10;* Is there any bridge or road work?&#13;&#10;* Do any operations involve: demolition, blasting, wrecking, high voltage, or high pressure boilers?&#13;&#10;* Any repair, installation, or servicing of burglar alarms, fire extinguishing, sprinkler systems, or radon mitigation systems?&#13;&#10;* During the last five years, has the customer been indicted for or convicted of any degree of the crime of fraud, bribery, arson, or any other arson-related crime in connection with this or any other property?&#13;&#10;* Has the customer declared bankruptcy, or had any tax lien, judgement or foreclosure or repossession within the last five years?&#13;&#10;* Are any locations Lessor’s Risk (customer rents out a building they own to another party)?

Do any of the above apply?

YesNo

Primary Business Classification:

Other Classifications:

Rows	Yes	No
Carpentry (NOC)
Carpentry - Interior
Carpentry - Construction of Residential Property not exceeding three (3) stories in height
Ceiling or Wall Installation - Metal
Door, Window or Assembled Millwork - Installation - Metal
Dry Wall or Wallboard Installation
Floor Covering Installation - Not Ceramic Tile or Stone
House Furnishings Installation
Insulation Work - Mineral
Insulation Work - Organic or Plastic in a Solid State
Insulation Work - Plastic
Masonry
Painting - Exterior - Buildings or Structures - three (3) stories or less in height
Painting - Interior - Buildings or Structures
Paperhanging
Plastering or Stucco Work
Siding Installation
Tile, Stone, Marble, Mosaic or Terazzo Work - Interior Construction

Do you perform ground-up construction of new residential homes?

YesNo

Do you perform any roofing?

YesNo

Does the customer act as a General Contractor?

YesNo

Does the customer act as a subcontractor framing new residential homes?

YesNo

What year was the business started?

Annual Sales:

Number of Employees:

Payroll (excluding owners):

Number of Owners:

Are subcontractors used?

YesNo

What % of the annual sales are subcontracted?

Do you obtain certificates of insurance from all subcontractors with limits that are at least $1,000,000?

YesNo

Are you added as an additional insured on the subcontractors’ policies?

YesNo

Do you currently have a general liability or BOP insurance policy?

YesNo

For the past year or more, have you had continuous insurance coverage?

YesNo

Have you incurred any commercial property or general liability losses in the past 5 years?

YesNo

If yes, please explain:

Do you have Worker’s Compensation coverage in force?

YesNo

Do you provide architectural or engineering design services?

YesNo

Any type of roofing work?

YesNo

Any spraying methods used?

YesNo

Do you do any work over 3 stories?

YesNo

Do you do any government contract work?

YesNo

Do you do any work in tract developments (26 units or more)?

YesNo

If yes, provide brief description of work performed

Do you do any oil field work?

YesNo

Do you do any foundation or footing construction / repair?

YesNo

Do you do any conversion of:

Rows	Yes	No
Commercial buildings to condominiums?
Apartment buildings to condominiums?

Desired Amount of Coverage for Tool and Equipment (if any):

The Applicant, Agent and/or Broker represents that the above statements and facts are true and that no material facts have been suppressed or misstated.

Completion of this form does not bind coverage or commit the Company to policy issuance.

NOTICE TO APPLICANTS (EXCEPT CO & NY):

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance may be guilty of a crime and may be subject to fines or confinement in prison.

NOTICE TO COLORADO APPLICANTS:

It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claiming with regard to a settlement or award payable for insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

NOTICE TO NEW YORK APPLICANTS:

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

Applicant Name

First NameLast Name

Date

MonthDayYear