Thank you for allowing Pledge Risk-Management Insurance Services the opportunity to save you money on your Insurance. Please fill out the information below and click the "submit" button.
Insured/Business Name
Email
example@example.com
Loss History
Please Select
In Business under 3 years- No losses
In Business 3-5 years- No Losses
In Business 5+ years- No Losses
Have Losses
Coverage Limits:
Please Select
500/500/500
500/1000/500
1000/1000/1000
1000/2000/1000
1000/2000/2000
Medical Expense
Please Select
$5000
$10000
Fire Legal Liability
Please Select
$50000
$100000
Deductable (Per Claim)
Please Select
$500
$1000
$2500
$5000
$10000
Total Gross Receipts (Next 12 Months)
Sub-Contractor Costs (Next 12 Months)
Employee Payroll (Next 12 Months)
Owner Payroll and/or Draw (Next 12 Months)
Effective Date
/
Month
/
Day
Year
Desired date to begin coverage
Years in Business
Years of Industy Experience
Description of operations
Please indicate your percentage of work that is:
New Construction
Remodel/Service/Repair
Residential
Commercial
Industrial
Classes of Business
Class Code
Description
% of Total Gross Receipts
1
2
3
4
Excess Liability Coverage
Please Select
None
1,000,000
2,000,000
3,000,000
4,000,000
5,000,000
Do you require subcontractors to have a written contract, provide certificates of insurance showing limits of liability equal to or greater than those on your policy:
Yes
No
N/A
Any exterior work exceeding three (3) stories in height:
Yes
No
N/A
Work on condominiums, townhouses, or Tract Develpoments with more than 15 units:
Yes
No
N/A
Any work with student housing, senior housing, assisted living facilities, or retirement homes involving more than one (1) individual unit within the development:
Yes
No
N/A
Work on slopes greater than 15 degrees or retaining walls higher than 6 feet:
Yes
No
N/A
Any installation or work with wood, coal, or waste oil‐burning stoves:
Yes
No
N/A
Any work involving mold, asbestos, environmental remediation, or herbicides/pesticides:
Yes
No
N/A
Any installation of fire extinguishing systems or monitoring of alarm systems:
Yes
No
N/A
Any work on railroads, traffic lights, airports, recreation facilities, petroleum plants, chemical facilities, elevators, escalators, retrofitting, or foundation repair/stabilization:
Yes
No
N/A
Any swimming pool installation, work with fiber optics, or tunneling operations:
Yes
No
N/A
Have you filed bankruptcy in the past 7 years:
Yes
No
N/A
During the past three years has any company ever cancelled, non‐renewed, declined, or refused to issue similar insurance:
Yes
No
N/A
Have you had any general liabilty insurance claims in the past 3 years:
Yes
No
N/A
Do you have knowledge of any event that may result in a general liability insurance claim:
Yes
No
N/A
Do you perform work on residential projects valued over $2 million
Yes
No
N/A
Submit
Should be Empty: