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CONTRACTOR QUOTE REQUEST FORM

Please fill out the form: In order to give you the best quote, please try to answer all the questions. Type "N/A" on any question that doesn't apply to you.

Section 1: General Information
Name:
Current Address:
Home phone Number:
Work phone Number:
Mobile phone Number:
E-mail Address:
Location Address:
Individual Corporation Partner Joint Venture Other
Specify Other:
Inspection/Audit Phone:
Proposed Policy Period: (mm/dd/yyyy)	From:
	To:
Section 2: Underwriting
Years in business:
Years of experience in this field:
Your contractor's license number:
Type of license:
Section 3: Please, Indicate the percentage of each type of work performed.
Commercial:		New Construction:
		Renovation:
Residential:		New Construction:
		Renovation:
Industrial:		New Construction:
		Renovation:
% of Total Operations:		New Construction:
		Renovation:
Section 4: Please indicate the percentage of work you perform as a General Contractor or as a Sub-Contractor
General Contractor:
Sub- Contractor:
Indicate the percentage of work performed by:
Your Employees:
Sub-Contractor under your supervision:
Do you have a written safety program?:		Yes No
Describe what safety precautions are in place:
How do you protect the general public from potential injury?:
Is Jobsite security provided at night:		Yes No
If "yes", please describe:
What is the maximum height of building you work on?
Does a foreman or qualified individual inspect all jobs upon completion?:		Yes No
Have you ever or do you currently perform work in?:		Arizona California Colorado Nevada Oregon Utah Washington None
Have you ever used,sold, install or removed asbestos?:		Yes No
If "yes", please explain in details:
Does the applicant draw plans, designs or specifications?:		Yes No
If "yes", please describe:
Does the applicant lease equipment to others with or without operators?:		Yes No
If "yes", describe equipment:
Do you employ a soil engineer?		Yes No
If no, do you hire an independent soil engineer?:		Yes No
If yes, does he/she name you as Additional Insured?:		Yes No
Do you offer warranties?:		Yes No
Section 5: Special Hazards
Do any of your operations involve the following?:
Use of Cranes:		Yes No
Blasting:		Yes No
Use of Tower Cranes:		Yes No
Pile Driving:		Yes No
Shoring or Underpinning:		Yes No
Caisson or Cofferdam work:		Yes No
Length of Boom:		Yes No
EIFS (Exterior Insulation & Finish Systems):		Yes No
Other Special Hazards:		Yes No
If "yes", please describe:
Section 6: Controlling the Subcontractor's Exposure:
If you NEVER hire subcontractors please check here
Are certificates of insurance required from subcontractors?:		Yes No
Do your subcontractors carry coverage or limits less than yours?:		Yes No
How long are Certificates of Insurance kept?:		Until job ends One year Other N/A
Are written contracts including a hold harmless clause in your favor obtain from all contractors?:		Yes No
Are you named as an additional insured on the subcontractor's policy?:		Yes No
Section 7: Limits Requested
General Aggregate:
Products & Complete Operations Aggregate:
Each Occurrence:
Personal & Advertising Injury:
Damage to premises rented to you:
Medical Expense:
Section 8: Type of Work Performed
Please indicate whether the following trades are performed by your employees or by subcontractors.
Bridge Construction:
Employee Subcontractors | Total:
Carpentry:
Employee Subcontractors | Total:
Concrete:
Employee Subcontractors | Total:
Debris Removal:
Employee Subcontractors | Total:
Drilling:
Employee Subcontractors | Total:
Drywall:
Employee Subcontractors | Total:
Electrical:
Employee Subcontractors | Total:
Excavation:
Employee Subcontractors | Total:
Framing:
Employee Subcontractors | Total:
Grading:
Employee Subcontractors | Total:
Guard rail installation:
Employee Subcontractors | Total:
Interior Demolition:
Employee Subcontractors | Total:
Landscaping:
Employee Subcontractors | Total:
Masonry:
Employee Subcontractors | Total:
Painting:
Employee Subcontractors | Total:
Parking lot paving:
Employee Subcontractors | Total:
Plumbing:
Employee Subcontractors | Total:
Roofing:
Employee Subcontractors | Total:
Street Paving:
Employee Subcontractors | Total:
Stucco:
Employee Subcontractors | Total:
Other:
Employee Subcontractors | Total:
Section 9: Experience
List Receipts for the last 3 years:
Year:		Gross Receipts:
Year:		Gross Receipts:
Year:		Gross Receipts:
Anticipated Gross Receipts for this term:		Gross Receipts:
Section 10: Certificate Recipients/ Additional Interest
Full Name:
Address:
Relationship to Applicant:
Additional Insured Certificate
Full Name:
Address:
Relationship to Applicant:
Additional Insured Certificate
Section 11: List 5 of your largest jobs in the last five years
1.
2.
3.
4.
5.
Section 12: Prior Carrier History (Last 3 Years)
Year:		Carrier:
Policy#:		Limits:
Premium:
Year:		Carrier:
Policy#:		Limits:
Premium:
Year:		Carrier:
Policy#:		Limits:
Premium:
Section 13: Loss Information
Date of Loss: (mm/dd/yyyy)
Type of Loss:
Description of Loss:
Amount Paid:
Reserve:
During the past years, has any company ever cancelled, declined or refused to issue any similar insurance to the applicant?:		Yes No
If "yes", please explain: