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Affordable Health Care Act
 Builder Contractor GL Quote 
Builder/Contractor General Liability Insurance Quote

Contact Information
Name of Business:
Inspection Contact Name:
Address:
City:
State: Zip:
Location Address:
City:
State: Zip:
Business Phone:
Fax Number:
Contact Email Address:
Business Status:
Years in Business:
Current Insurance Information
Current Insurance Carrier: Premium:$
Effective Date: Expiration Date:
Please List Any Other Previous Carriers Over the Past 3 Years Below:
Carrier Name: Premium:$
Carrier Name: Premium:$
Project/Work Information
Please write a Description of Operations below:
What % of your work is:
(each line must total 100%)
Commercial % % Industrial % Residential %
New Construction % Remodel/Additions %
Whatpercentage of your work is as a:
General Contractor: % Subcontractor: %
What percentage of your work is
Subcontracted Out: % Sub Costs:$
Do you collect certificates of insurance at a $1,000,000 limit?
Yes No
Receipts / Payroll / Dollar Value Info
Gross receipts for the past 3 years:
and the next 12 months:
(3rdyrprior)$
(2ndyrprior)$
(Last12months)$
(Next12months)$
Number of owners/officers/partners active
at the job site or supervising:
Payroll of employees excluding owners,
officers, partners & clerical:
$
Dollar value of average job completed
includingallmaterials,labor&equipment:
$
Describe any project(s) underway or planned for the next year, including values below:
Miscellaneous and Legal Info
Have you ever performed ground up construction involving condominiums, townhouses, apartments, or single family tract developments of two (2) or more?:
Yes No
Have you ever been named in litigation regarding faulty construction?:
Yes No
Are there any claims or legal actions pending?:
Yes No
Do any of the entities named in the application have knowledge of any pre-existing act, omission, event, condition or damages to any person or property that may potentially give rise to any future claim or legal action against any such entity?:
Yes No
Claims History
Claim #1 Claim Status: Closed Open
Date of occurrence:
Date of claim:
Type description of occurrence or claim:
Amount paid on your behalf: $
Amount reserved: $
Claim #2 Claim Status: Closed Open
Date of occurrence:
Date of claim:
Type description of occurrence or claim:
Amount paid on your behalf: $
Amount reserved: $
Additional Comments
Please give any additional comments or questions

No coverage of any kind is bound or implied by submitting information via this online form

  • Information from you and other sources, such as your driving, claims and insurance histories, may be used to calculate an accurate price for your insurance.
  • We will not distribute information to other parties other than for insurance underwriting purposes.
  • By submitting this form, you agree to release us from any liability should this information be accidentally viewed by others.

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