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Name
2.

Contact
3.

Business
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Name

Company Name/DBA

Contact Name / First Name

Last Name

Contact

Phone

State

Zip Code

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Business

Type of Insurance needed (check all that apply)

[group General-Liability] Description of Operations Gross Receipts What Percentage of work do you subcontract out? Field Payroll Any general liability claims in the past 3 years?NoYES [group GL-Claims-3years] No. of Claims [/group] Year of Experience [/group]

[group Worker-Compensation] Description of Operations Payroll, not including owners and office employees Does the owner(s) want to be included or Excluded? Any workers compensation claims in the past 3 years?NoYES [group FEIN-SSN] *Optional, though we do need this information to get a quote* FEIN or SSN [/group] [/group]

[group Inland-Marine] Dollar amount of total worth of equipment Dollar amount of the most expensive/valuable piece of equipment VIN/Serial number for scheduled equipment [/group]

[group Commercial-Auto] Number of vehicles you want covered Coverage VIN number of vehicle? Any modifications to vehicle? *Optional, though we do need this information to get a quote*NoYES [group DL-No-DOB] Drivers License DOB [/group] [/group]

[group Builders-Risk] Address of the jobsite Value of existing structure? (If vacant lot put $0) Value of work being performed Square footage of build How many stories Any protective safeguards? EX: Burglar alarms, fenced jobsite, etc NoYES How long will the build take? [/group]

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Desired Effective date

Additional notes