Contractor Liability Short Form

INSTRUCTIONS Complete all required* areas, then click the submit button. We will contact you with a premium estimate. Coverage cannot be bound using this form.

Date *

Company Name *

Your Name *

Phone *

Email *

Address *

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Type of Entity *

-----Corporation-----Partnership-----Sole Proprietor-----LLC-----Other (describe below)

Number of Years/Experience *

Number of Years in Business *

Contractors License Number *

Type of Contractor *

-----General Contractor-----Subcontractor (describe below)-----Other (describe below)

Describe Trade (Plumbing, Electrical, HVAC, etc) *

Residential-Commercial - check all that apply *

-----Residential Work-----Commercial Work-----Other (describe below)

What percentage of your work is Residential vs Commercial? *

Type of Work (past 10 years) - check all that apply *

-----Remodel/Additions-Single Family-----Remodel/Additions-Multi-Family-----Remodel/Additions-Condo/Townhouse/Loft-----Remodel/Additions-Commercial Work-----New Construction-Single Family-----New Construction-Multi-Family-----New Construction-Condo/Townhouse/Loft-----New Construction-Apartments-----New Construction-Tract Homes-----New Construction-Commercial Work-----Other (describe below)

Describe "Other" Type of Work (if any)

Claim/Loss Experience (4 prior years) *

-----No Claims-4 years-----Yes,I've had claims (describe below)

Describe all claims (if any)

Date of Claim, Amount Paid, Description

Payroll (exclude owner & clerical) *

Subcontractor Costs *

Gross Receipts *

Do you obtain Certificates of Insurance from Subcontractors *

-----Yes-----No

Do you require minimum limits of $1,000,000 *

-----Yes-----No

Are you named as an additional insured *

-----Yes-----No

Message:

*required entries

CONTRACTOR LIABILITY-SHORT FORM

12 Month Projection (estimate)

Certificates Of Insurance

Verification