Contractor General Liability Quote Form

Your Personal Data

Your Name:

Street Address:

City:

State: (Must be Pennsylvania)

Zip Code:

E-Mail (REQUIRED):

E-Mail again for accuracy:

Phone:

Fax (optional):

Business Underwriting Information

Type of operation:

Describe operations in detail:

License class:

License Number:

Limit of Liability
Coverage Requested?

$300,000
$500,000
$1 Million

Currently Insured?

Yes No

Name of Carrier & how long insured?

Prior Claims?

Yes No

Describe claims in detail:

Years in business:

Years experience in field:

Percentage of work residential:

Percentage of work commercial:

Number of Active Owners:

Number of Employees:

0 1 2 3+

Annual Employee Payroll: $

Annual Gross Sales: $

Do you subcontract work?

Yes No

(If yes, what percentage of your work
is subbed, and what kind of work?)

Do you do foundation work?

Yes No

Do you work on condos?

Yes No

Employees paid over $18/hour?

Yes No

Do you have a safety program?

Yes No

Comments/Remarks
(describe any scheduled jewelry, in-home business, or other special coverages needed here):

Send my quotation via:

E-Mail Fax
Regular Mail
Call me by Phone


Contractor General Liability Quote Form One Simple Form - takes only 2-3 Minutes! Your Personal Data
Your Name:
Street Address:
City:
State: (Must be Pennsylvania)
Zip Code:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Phone:
Fax (optional):

Business Underwriting Information
Type of operation:
Describe operations in detail:
License class:
License Number:

Limit of Liability Coverage Requested?	$300,000 $500,000 $1 Million

Currently Insured?	Yes No
Name of Carrier & how long insured?
Prior Claims?	Yes No
Describe claims in detail:

Years in business:
Years experience in field:
Percentage of work residential:
Percentage of work commercial:

Number of Active Owners:
Number of Employees:	0 1 2 3+
Annual Employee Payroll: $
Annual Gross Sales: $

Do you subcontract work?	Yes No
(If yes, what percentage of your work is subbed, and what kind of work?)
Do you do foundation work?	Yes No
Do you work on condos?	Yes No
Employees paid over $18/hour?	Yes No
Do you have a safety program?	Yes No
Comments/Remarks (describe any scheduled jewelry, in-home business, or other special coverages needed here):

Send my quotation via:	E-Mail Fax Regular Mail Call me by Phone