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Contractor Insurance

Contractor Questionnaire

​WE ARE HERE TO HELP YOU SAVE MONEY !

Thank you for giving us the opportunity to serve your insurance needs. 

Once you complete the form below, our office will contact you for more information to offer a FREE quote. Should you have any questions, please feel free to CALL us @ (844) 544-7475

Business Name *

What is the filing status of your company?

Owner's Name

Street Address

Email *

Business Phone Number *

Please enter a valid phone number.

Cell phone Number

Please enter a valid phone number.

Is your policy based on Payroll or Sales?

Approx. Annual Field Workers Payroll?

Any exterior work over 3 stories? (General Contractors, Plumbers, Electricians)

Any losses in the past 5 years?

General Liability Insurance Company

Workers Comp. Insurance Company

Disability Insurance Company

Commercial Auto Insurance Company

Tax ID # (EIN)

Is this a new business:

Business Address *

City *

Zip Code *

State *

Number Of Owner's

Business operations descriptions and radius of work.

Please mention what boroughs you work in.

Do you work more on Residential or Commercial?

Approx. Annual Gross Sales?

​Do you use sub-contractors?

​Upload Current Loss Runs if Available

Upload File

Current GL Policy Expiration Date

Current WC Policy Expiration Date

Current DBL Policy Expiration Date

Current CA Policy Expiration Date

Please put N/A if no auto.

Please upload current General Liability, Workers Comp. and Commercial Auto policies with list of DRIVERS to quote properly.

Upload File

Agent Name: (For internal Use Only)

Your Submission has been recieved, Thanks for contacting us.

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