General Liability Insurance Quote

General Liability Insurance Quote for Contractors

Name * First Last
Business Name
Mailing Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Physical Address Location (if different from Mailing Address)
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Type of Organization Corporation Partnership Proprietorship Individual **Other
If other, please specify:
Years in Business
Contact Name
Contact Phone # * - (###) - ### ####
Fax #
Email
Name of Current Insurance Company (not Agency or Broker name)
How Long Have You Been Insured With Current Company
Any claims in the Last Three (3) Years? Yes No
If Yes, please provide date of loss and description of claim:
Contractors License Type:
Describe your business operations: (i.e. residential plumbing, residential electrical, finish carpentry, etc.) and indicate the % of work performed for each operation performed:
Estimated Annual Gross Receipts $
Estimated Annual Gross Payroll $
Estimated Annual Cost of Sub-Contractors $
Liability Limit $
**If other, please specify Liability Limit:
Please list any other coverages needed: