Contractor – Land Based Quote

Last Name(Required)

First Name(Required)

Email(Required)

Website

Phone(Required)

EIN(Required)

If no EIN please provide Social

Business Name(Required)

County (Business Location)(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Describe business operations(Required)

How many years has applicant been in business?(Required)

How many years does applicant personally have in trade to be insured?(Required)

How many claims or losses does applicant have within last three years?(Required)

Does applicant have prior insurance with no more than 10 day lapse?(Required)

Inland Marine Coverage needed?(Required)

Scheduling of Tools or adding a 2nd policy just for tools may be an option. Please send a separate email if interested with description and value of individual tools you may want covered.

Expected Gross Receipts(Required)

Cost of work to INSURED Subcontractors(Required)

Type of work done by INSURED SUBCONTRACTORS(Required)

# of Full time Administrative or Clerical Employees(Required)

Annual payroll of Full time Administrative or Clerical Employees(Required)

# of Part time Administrative or Clerical Employees(Required)

Annual payroll of Part time Administrative or Clerical Employees(Required)

# of Full Time Sales Employees(Required)

Annual payroll of Full Time Sales Employees(Required)

Number of Part Time Sales Employees(Required)

Annual payroll of Part Time Sales Employees(Required)

Active Partners, Owners, Directors, Officers(Required)

Please provide any additional information that may help us help you with your insurance needs.(Required)

Have other agencies not been able to help & Why? Anything different about your operation than another similar business (something special)?

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Contractor – Land Based Quote

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904-347-6727