Contractor Quote Form |
|
| Name |
|
| Address |
|
| City |
|
| State |
|
| Zip/Postal Code |
|
| Phone |
|
| E-Mail |
|
| Trade or Occupation Select One |
|
| If other, please explain |
|
| Business Name |
|
| Contact Name |
|
| Type of Business |
Individual
Corporation
Partnership
Other
|
| In Business For 3 or More Years ? |
Yes
No |
| Number of Employees |
Full Time
Part Time |
| Estimated Annual Payroll |
|
| Do You Carry Worker Compensation Coverage? |
Yes
No |
| If Yes, Company |
|
| Do You Use Subcontractors? |
Yes
No |
| Do you Hold any Professional Trade Licenses? |
Yes
No |
| If Yes, License Number |
|
| Any Claims Submitted During the Past Three Years? |
Yes
No |
| Description of Claim Including Date and Amount Paid |
|
| Proposed Effective Date of Coverage |
(xx/xx/xx) |
| Policy Term 12 Months From Effective Date |
Annual
Semi- Annual (60/40)
Quarterly (40/20/20/20)
|
| Limits of Insurance |
$300,000 Each Occurrence / $600,000 Aggregate
$500,000 Each Occurrence / $1,000,000 Aggregate
$1,000,000 Each Occurrence / $2,000,000 Aggregate
- Fire Legal Liability Limit : $50,000
- Medical Payments to Others Limit : $5,000
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