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Contractors GL & WC

Information Request for Contractors Insurance

General Liability

Company Name

FEIN #

Unemployment ID #

Owner Name

Phone #

E-mail

Fax #

Date of Birth

Social Security #

Business Mailing Address

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

Description of Work Performed

% Commercial Work

% Residential Work

Years Experience in Trade

Estimated Annual Gross Sales: $

Estimated Annual Subcontracted Work: $

What type of work do you Subcontract?

General Liability Limit

$300,000/$600,000

$500,000/$1,000,000

$1,000,000/$2,000,000

Tool Coverage

Deductible

$250

$500

$1,000

Last 4 Jobs

Description

Cost $

Duration

Description

Cost $

Duration

Description

Cost $

Duration

Description

Cost $

Duration

Workers Compensation

Principal/Owner Covered

YES

other Covered Family Members

Estimate Annual Payroll for Covered Employees: $

Email information to: [email protected] (optional)