Contractor Insurance Quote Form

January 9, 2013

Contractor Insurance Quote Form

We Make It Easier  for you to get a contractor insurance quote. Here is what you should know about this process and resulting quote:

  • We will provide a quote from at least 2 different insurance companies. There are likely to be slight differences in coverage, limits and deductibles.
  • The more current information you can provide, the closer this quote will be to your actual premium.
  • The resulting quotes will not likely show discounts for having other types of insurance or multiple policies with us. When you decide to move forward with us, we will handle that issue (and others) personally.
  • The quote process will take approximately 6-8 minutes.

Thank you in advance for taking the time to complete our application! If we need additional information to complete your quotes, we will contact you. Otherwise we will get back to you within 24 hours! 

Name: *
E-mail: *
Phone Number:
Name of Business: *
Business Street Address:  *
Suite or Unit Number:
City, State, Zipcode: *
Legal Entity/Status *
Will this replace an existing business policy? *
Number of years in business: *
Gross Annual Payroll:  *
Gross Annual Revenue:  *
Subcontractor Costs:  *
Years of owner experience within industry:  *
Number of Full Time Employees:  *
Number of Part Time Employees: *
Description of your business: *
Desired Liability Limits:  *

Indicate the percentage of construction work to be performed by you or on your behalf by subcontractors during the next twelve months: (Each line should add up to 100%)


Residential + Commercial/Industrial: *

Residential: 

New Construction + Remodeling:  *
Inside Building + Outside Building: *

Commercial/Industrial: 

New Construction + Remodeling; *
Inside Building + Outside Building; *

Indicate the percentage of construction work performed by you or on your behalf by subcontractors during the past five years: 

Residential: 

New Construction + Remodel: *
Inside Building + Outside Building:  *

Commercial/Industrial: 

New Construction + Remodel:  *
Inside Building + Outside Building;  *

Indicate the anticipated percentage of construction work over the next twelve months to be performed by you using percentage of  Direct Payroll under “Direct” and percentage of Subcontractor cost under “Subbed” as the basis. If not anticipating work in a particular area, input 0%, 0%:

Blasting:  *
Excavation:  *
Plumbing:  *
Boiler:  *
Fire Suppression:  *
Roofing:  *
Bridge Building: *
Gas Main:  *
Seismic:  *
Retro-Fitting:  *
Carpentry:  *
Grading:  *
Sewer/Water:  *
Concrete:  *
Hazardous Material:  *
Steel (Structural):  *
Crane Rental:  *
HVAC: *
Steel (Ornamental):  *
Demolition:  *
Insulation:  *
Street/Road:  *
Drilling:  *
Maintenance:  *
Stucco:  *
Drywall:  *
Masonry:  *
Supervisory Only:  *
Earthquake Repair:  *
Mechanical:  *
Tanks:  *
EIFS/Synthetic Stucco:  *
Painting:  *
Water-Proofing:  *
Electrical Plastering:  *
Other:
Have you been cited or fined by OSHA in the past 5 years?  *
Do you currently furnish a performance and/or payment bond to any person or organization? *
If yes, name of Surety/Insurance Company:
Have you defaulted on a performance and/or payment bond in the last three years? *
Indicate the type of security used at job sites and at your premises: *
Have you allowed, are you currently, or will you ever allow your license to be used by any other contractor for a project on which you have not worked?  *
Has any licensing authority taken any action against you? *
Do you operate your business from a private residence?  *
If yes, please provide the name of your Homeowners Insurance carrier and your Liability Limits:
Have you built, are you currently, or will you build on hillsides, terraces, landfills, or subsidence areas?  *
If yes, Explain:
Have you built, are you currently, or will you construct buildings in excess of two (2) stories or any structure in excess of thirty feet in height?  *
If yes, provide details on the work performed including whether scaffolding or aerial lifts are/were used:
Have you performed, are you currently, or will you or your subcontractors perform any work below grade? *
If yes, maximum depth:
And percentage of operations:
Have you worked, are you currently, or will any of your employees work under U.S. Longshore and Harbor Workers' Compensation Act or Jones Act? *
Do you have any operations other than construction?  *
Do you have any operations covered by other insurance?
If yes to either of the two previous questions, please explain:
Do you execute written contracts including indemnification clauses in your favor with all independent contractors performing work for you? *
If no, please explain exceptions:
Do your written contracts with your independent contractors require the independent contractor to maintain Commercial General Liability insurance including you as an Additional Insured? *
If yes, minimum limits of insurance required?
If no, please explain exceptions:
Do your written contracts with your independent contractors require the independent contractor to maintain Commercial General Liability insurance that is primary to and non-contributing with your insurance?  *
Do your written contracts with your independent contractors require the independent contractor to maintain Workers Compensation insurance?  *
If no, please explain exceptions;
Do you subscribe to a Certificate of Insurance management service or have a written procedure for obtaining and maintaining current Certificates of Insurance from your independent contractors? *
If yes, please provide details including the vendor name and when the service or procedure was first established:
Do you maintain copies of contracts and Certificates of Insurance for a minimum of ten years? *
If no, for how long?
Do you contractually agree to defend or indemnify or provide Additional Insured coverage for property owners, property managers, or general contractors for whom you are performing work? *
If yes, approximately how many persons or organizations will require Additional Insured coverage during the upcoming year?
Also, if yes, are your contracts reviewed by outside counsel prior to execution of the contract?
Are you responsible for job-site safety on your projects?  *
Do you employ a full time safety director and have a formal written safety program? *
Is your job supervisor's remuneration dependent upon job-site safety results? *
If yes, what percentage?
Do you maintain Workers Compensation Insurance? *
Do you automatically provide a warranty program for your customers?  *
If yes, please explain:
Is your warranty program insured?  *
If yes, please explain;
During the past five years, has any insurer ever cancelled, declined, or refused to issue similar insurance to any applicant?  *
If yes, explain:
Has any lawsuit ever been filed or any claim otherwise been made against your company, or any partnership, joint venture, or limited liability company of which you have been a member, or your predecessor(s) in business, or against any person, company, or entities on whose behalf your company has assumed liability? (For the purpose of this application only, a claim means a receipt of a demand for money, services, or arbitration.)  *
Are you or is your company aware of any facts, circumstances, incidents, situations, damages, or accidents (including but not limited to faulty or defective workmanship, product failure, construction dispute, breach of contract, property damage, or construction worker injury) that a reasonably prudent person might expect to give rise to a claim or lawsuit, whether valid or not, which might involve the company?  *
Have you had any losses in the last 5 years? *
If yes, explain;
What are the 5 largest projects you have completed over the past five years? Please state the location, date, work performed, and total gross receipts for the work performed.  *
Do you have any ongoing or upcoming projects for the current year? If so, please explain:  *
Will any of your work during the next twelve months be insured under a Wrap Up (or Owner-Controlled) Insurance Program?  *
Please state your current CGL Insurance Carrier, Limits, Deductible/Retention, and Premium:  *
Desired Limits:  *
Desired Deductible/Retention:  *
Your Company's Website Address:
Age of building your business occupies:  *
Construction Type:  *
Number of Stories:  *
Total Square Footage of Building:  *
Square footage of space occupied by this business: *
Burglar Alarm Type: *
Fire Alarm Type:  *
Desired Deductible Amount:  *
Physical Building Coverage Limit:  *
Business Personal Property Amount:  *
Additional Properties to Insure? *
If yes, how many?  *
Any other questions or comments for us?
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