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Type of Business/Organization:
*
Sports & Recreation
IT Professional
Product Manufacturer/Distributor
Contractor
Other Small Business
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Contact Information
General Liability and Workers Compensation available only in DC, FL, GA, IN, MD, MS, NC, PA, SC, TN, VA.
Click here for a Builders Risk/Course of Construction Insurance quote
(available in all states except HI and AK).
Organization Name
*
Contact Name
First
Last
Address:
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
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Texas
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State
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Email:
*
Website:
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Operations
Please provide several sentences to describe in detail your operations and typical jobs.
*
Please provide several sentences to describe in detail your business operations.
*
Please provide several sentences to describe in detail your operations and the types of products that you sell.
*
Operations Information
Years Of Operation Under Current Business Name:
*
If none, please enter 0.
Please provide several sentences to describe in detail your operations and/or products.
*
Are you a start-up
*
Yes
No
Do you currently have insurance?
*
Yes
No
If yes, what is the name of the current carrier (not agency)
*
When Will You Be Ready To Buy?
*
Today
Tomorrow
Within the Next 3 Days
Within the Next 7 Days
Within the Next Month
Within the Next 6 Months
Other
Please indicate the policy types for which you are requesting a quote:
General Liability
Errors & Omissions
Auto
Property
Worker's Compensation
Equipment
Builder's Risk
Directors & Officers Liability
Employment Practices Liability
Cyber Risk
Other
Business Entity Type:
Corporation
LLC
Partnership
Individual
Municipality
Health Club
Other
Type of Contractor:
*
Builder
Remodeler
Light Commercial General Contractor
Trade Contractor
Other
Years Of Experience By Owner(s) In This Field:
*
If none, please enter 0.
% of Work Residential:
*
% of Work Commercial:
*
Do You Have Employees Other Than Owners?
*
Yes
No
Do You Use Uninsured Subcontractors?
*
Yes
No
Do You Use Insured Subcontractors?
*
Yes
No
Owners
Name
*
Work Description
Estimated Annual Payroll
*
Example: John Smith
Executive Supervisor
$45,000
W-2 Employees Who Are Not Owners
Please enter "none" in all 3 boxes on the first line if there are no W-2 employees who are not owners.
Work Description
*
# of Employees
*
Estimated Annual Payroll
*
Example: Framing
3
$80,000
1099 Uninsured Subcontractors
Work Description/Classification
*
Estimated Annual Amounts Paid
*
Example: Land Clearing
$110,000
Insured Subcontractors
Estimated Annual Amounts Paid To All Insured Subcontractors Combined
*
If none, please enter "none" in the field.
Types of Policies To Be Quoted
General Liability
*
Yes
No
Current General Liability Carrier:
Current General Liability Premium:
Workers' Compensation:
*
Yes
No
Current Workers' Compensation Carrier:
Current Workers' Compensation Premium:
Builders Risk:
*
Yes
No
Current Builders Risk Carrier:
Current Builders Risk Premium:
Auto:
*
Yes
No
Current Auto Carrier:
Current Auto Premium:
Property:
*
Yes
No
Current Property Carrier:
Current Property Premium:
Equipment:
*
Yes
No
Current Equipment Carrier:
Current Equipment Premium:
Why Are You Requesting A Quote Today?
*
I do not have current coverage.
My current coverage was cancelled or non renewed.
I want to make sure my current price is competitive.
I am not happy with my current agent.
Other
When Will You Be Ready To Buy?
Today
Tomorrow
Within the Next 3 Days
Within the Next 7 Days
Within the Next Month
Within the Next 6 Months
Other
Insurance & Loss History
Any policy been cancelled or non renewed in past 3 years?
*
Yes
No
If yes, please explain policy type and reason:
Losses under any policy in past 3 years?
*
Yes
No
If yes, please explain policy type, give brief description of claim, approximate date, and amount paid:
Comments:
Once you hit submit, your web form will be reviewed by an experienced contractor insurance specialist who will review your application and will be in touch if additional information is needed. In many cases, a proposal may be offered during the next business day.
