Tell us about you.
Name: Home Phone:
Street Address: Work Phone:
City: Email Address:
State: Zip:    


 

Organization Type:
Contractor Type:
Any Operation or Property Owned, Leased, or Occupied That Will Not be Covered by This Policy?
Have You Declared Bankruptcy or Had any Financial Problems in the Past 7 Years?
Have you Filed any Insurance Claims Within the Past 3 Years?
Do you Perform More Than 10% of Your Work in a State Other Than Your State of Domicile?
Percentage of Work Performed Within 50 Miles of Your Base of Operations:
Total Number of Owners, Officers, and Partners:
Total Number of Employees:
Total Monthly Payroll:
Number of Years Experience:
Amount of Sales Receipts for Current Year:
Amount of Sales Receipts for Prior Year:
Percentage of Work Which is Residential:
Percentage of Work Which is Commercial:


Please describe all "yes" answers below.

Complete if residential or remodeler contractor

Do you Require to be named as and Additional Insured on the Subcontractors Policy?
Do you Ever Act as a Construction Manager?
If Yes, Annual Fees:
Any Owned Autos?
Do you Build/Remodel Condos or Multi-Family Dwellings?
Do you Build/Remodel Commercial Buildings Exceeding 10,000 Square Feet?
Number of Housing Starts Current Year:
Number of Housing Starts Prior Year:
Percentage of Work Which is New Construction:
Percentage of Work Which is Remodeling:

Complete if trade contractor

Any Owned Autos?
Do you Perform Work at Landfill Sites or Have you Done so in the Last 10 Years?
Do you Install Automatic Sprinkler or Fire Suppression Systems or Done so in the Last 10 Years?
Do you Install Fire Alarms or Smoke Detectors or Done so in the Last 10 Years?
Do you Install, Service, or Repair high Pressure Boiler Systems or Done so in the Last 10 Years?
Do you Apply "Exterior Insulation Finish Systems" or Have you Ever Done so in the Past?
Do you do Any Remodeling Involving Foundation, Structural Changes, or Movement of Load Bearing Walls?
Minimum General Liability Limits Required of Subcontractors Per Occurrence:
Minimum General Liability Limits Required of Subcontractors Per Aggregate:


Complete only if requesting this coverage.
Any Mobile Equipment?
If Yes, Does Operator Have Less Than 2 Years Experience in Operating the Equipment?
If Yes, Please Comment:
Does this Mobile Equipment Have any Maintenance Program in Place?
If Yes, Please Explain:
Is Equipment Secured and Protected When Not in Use?
If Yes, Please Describe:



How would you like us to contact you regarding this quote? (You must check at least one method)
Email:        Standard Mail:        Fax:
Fax Number:
How Did You Hear About Us?
Comments:


All quotes provided are valid in Massachusetts only.

Quotes sent in the mail will go to the address provided at the top of this form in the applicant section.  If you'd like us to mail it to a different address, please let us know in the comments box above.

 

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