Contractor Liability

Customer Name*Contact Name*

Address*

City*State*ZIP Code*

Current Coverage*Effective Date*

Current Carrier*Current Premium($)*

BillingLeave empty if same as above.Country*

Phone*Fax*Cell*Nextel Private ID*

Email Address*FEIN/SS#*Year Business Started*

Direct employees of contractorBusiness TypeSole ProprietorCorporationPertnershipSubchapter

Managers/Owners Years’ ExperienceInsurance NeededGLAutoEquipmentPropertyUmbrellaWork Comp

Description of Operation*

General Liability

Limits*$300,000/$60,000,000$500,000/$1,000,000$1,000,000/$2,000,000

Total Direct Payroll($)*Gross Receipts($)*

*Owners and officers mandatory payroll used is $25,000 each

For Contractors

Are Subs Contractor Used?*

Total Sub-Contracted Work Cost($)*Insured Sub Cost($)*Uninsured Sub Cost($)*

5 Commercial Work*

% Residential Work*% Work Sub-Contracted*Type of work sub contracted*

Are Certificates required on subs?*

Notes

Submit