Account Representative / Referral Please select your account representative, or leave as "General Representative" if you do not have one: General Representative Carol McIsaac Donna Foster Judith Graham Kathy East Margaret Rosa Teresa Heupel Toni Peconi Referred By / To:

 

General Information Name of Business: Inspection Contact Name: Mailing Address: City:   State:   Zip: Location Address: City:   State:   Zip: Business Phone:   Fax: Contact Email Address: Business Status: Individual Corporation Partnership Joint Venture     Years in Business:

Current Insurance Information Company Name (not agency):     Premium: $ Effective Date:   Expiration Date: Please List Any Other Previous Carriers Over the Past 3 Years Below: Carrier Name:     Premium: $ Carrier Name:     Premium: $

Project/Work Information Please write a Description of Operations below: What % of your work is:  (each line must total 100%)   Commercial %  Industrial %  Residential % New Construction %   Remodel/Additions % What % of your work is as a:  General Contractor: %   Subcontractor: % What % of your work is: Subcontracted Out: %   Sub Costs: $ Do you collect certificates of insurance at a $1,000,000 limit?:   Yes     No

Receipts / Payroll / Dollar Value Info Gross receipts for the past 3 years:  and the next 12 months:  (3rd yr prior) $     (2nd yr prior) $ (Last 12 mths) $    (Next 12 mths) $ Number of owners/officers/partners active at the job site or supervising:      Payroll of employees excluding owners, officers, partners & clerical:    $ $ value of average job completed incl. materials, labor & equipment:   $ Describe any project(s) underway or planned for the next year, including values below:

Miscellaneous and Legal Info Have you ever performed ground up construction involving condominiums, townhouses, apartments, or single family tract developments of two (2) or more?:    Yes   No Have you ever been named in litigation regarding faulty construction?:    Yes   No Are there any claims or legal actions pending?:    Yes   No Do any of the entities named in the application have knowledge of any pre-existing act, omission, event, condition or damages to any person or property that may potentially give rise to any future claim or legal action against any such entity?:    Yes   No

 

Claims History Enter all claims or occurrences that may give rise to claims for the prior 3 years. This information is kept strictly confidential

Claim #1   Claim Status: Closed   Open Date of Occurrence:   Date of Claim: Type/Description of Occurrence or Claim: Amount paid on your behalf: $   Amount reserved on behalf: $

Claim #2   Claim Status: Closed   Open Date of Occurrence:   Date of Claim: Type/Description of Occurrence or Claim: Amount paid on your behalf: $   Amount reserved on behalf: $

 

Additional Comments Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough space, please enter them here.

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