CONTRACTORS GENERAL LIABILITY INSURANCE QUOTE QUESTIONNAIRE

COMPANY NAME:

CONTRACTOR LICENSE NUMBER:

OWNER'S FIRST NAME:

OWNER'S LAST NAME:

MAILING ADDRESS:

CITY:

STATE:

ZIP:

YEARS IN BUSINESS:

YEARS' EXPERIENCE:

EMAIL ADDRESS:

PHONE #:

FAX #:

WEBSITE:

ENTITY TYPE:

DESCRIBE OPERATION:

LIMITS OF COMMERCIAL GENERAL LIABILITY QUOTE DESIRED:

ANNUAL	GROSS SALES INCLUDING LABOR & MATERIAL & COT OF SUB	COST OF SUB INCLUDING LABOR & MATERIAL	NUMBER OF EMPLOYEES	EMPLOYEES PAYROLL INCLUDING LEASED LABOR (EXCLUDING OWNERS)	NUMBER OF ACTIVE OWNER (S)	OWNERS PAYROLL (IF ANY)
NEXT 12 MONTHS
PAST 12 MONTHS

WILL YOU USE SUBCONTRACTORS?

LIST THE TRADES OF SUBCONTRACTORS YOU USE:

AVERAGE JOB COST:

ESTIMATED NUMBER OF JOBS PER YEAR:

TYPE OF CONSTRUCTION YOU PERFORM?
NEW CONSTRUCTION - COMMERCIAL/INDUSTRIAL	%
REMODEL/ADDITION/REPAIR - COMMERCIAL/INDUSTRIAL	%
NEW CONSTRUCTION - RESIDENTIAL SINGLE HOMES	%
REMODEL/ADDITION/REPAIR - RESIDENTIAL SINGLE HOMES	%
NEW CONSTRUCTION* - APARTMENT	%
REMODEL/ADDITION/REPAIR* - APARTMENT	%
NEW CONSTRUCTION* - CONDOMINIUM/TOWNHOMES	%
REMODEL/ADDITION/REPAIR* - CONDOMINIUM/TOWNHOMES	%
TOTAL = 0%
TOTAL MUST EQUAL 100%

IN WHAT CAPACITY DO YOU OPERATE?
ARTISAN/SUBCONTRACTOR	%
GENERAL CONTRACTOR	%
DEVELOPER	%
OWNER BUILDER	%
PROJECT MANAGER	%
CONSULTANT	%
TOTAL = 0%
TOTAL MUST EQUAL 100%

*IF WORK DONE FOR CONDO/TOWN-HOME/APARTMENT/PUD'S/TRACT HOMES, IS THE WORK DONE FOR?

LIST YOUR TWO LARGEST PROJECTS WHICH HAVE PERFORMED DURING THE PAST 3 YEARS:

LOCATION - CITY	PROJECT TYPE	NATURE OF WORK	START DATE	END DATE	JOB RECEIPTS/COST

LIST YOUR CURRENT PROJECTS OR THOSE SCHEDULED TO COMMENCE OVER THE NEXT 12 MONTHS:

LOCATION - CITY	PROJECT TYPE	NATURE OF WORK	START DATE	END DATE	JOB RECEIPTS/COST

HAVE YOU AT ANY TIME BEEN INVOLVED OR PLANNING TO BE INVOLVED IN THE CONSTRUCTION OF NEW RESIDENTIAL OR COMMERCIAL BUILDING FROM THE GROUND UP IN THE NEXT YEAR? IF YES, HOW MANY?

PLEASE EXPLAIN

HAVE YOU AT ANY TIME BEEN INVOLVED OR PLANNING TO BE INVOLVED IN THE CONSTRUCTION OR DEVELOPMENT OF MORE THAN 5 SINGLE FAMILY NEW HOMES OR DUPLEXES, TRACT HOMES AND/OR RESIDENTIAL DEVELOPMENTS? IF YES, HOW MANY UNITS?
TYPE OF STRUCTURE

HAVE YOU AT ANY TIME BEEN INVOLVED OR PLANNING TO BE INVOLVED IN THE CONSTRUCTION OR DEVELOPMENT ASSISTED LIVING FACILITIES, RETIREMENT HOMES, MILITARY HOUSING, STUDENT HOUSING, OR ANY OTHER MULTI-UNIT FACILITY INTENDED FOR PERMANENT HABITATIONAL OCCUPANCY?
IF YES, HOW MANY UNITS? TYPE OF STRUCTURE

HAVE YOU PERFORMED, OR WILL YOU OR YOUR SUBCONTRACTORS PERFORM ANY WORK BELOW GRADE?
IF YES, WHAT IS THE MAXIMUM DEPTH? FT

DO YOU PERFORM WORK ABOVE TWO STORIES IN HEIGHTS? MAXIMUM STORIES MAXIMUM HEIGHTS FT

ANY WORK OUTISDE CALIFORNIA? IF YES, WHAT PERCENTAGE OF WORK IS OUTSIDE CA AND WHICH STATES?

INSURANCE INFORMATION: ARE YOU CURRENTLY INSURED? REQUESTED EFFECTIVE DATE , HAS AN INSURANCE COMPANY CANCELLED OR NON-RENEWED YOUR POLICY IN THE LAST 3 YEARS? HAVE YOU HAD ANY LOSSES OR CLAIMS DURING THE LAST 5 YEARS? IF INSURED NOW, PLEASE PROVIDE INSURANCE POLICY INFORMATION BELOW - LOSS RUNS ARE REQUIRED – PLEASE EMAIL OR FAX THE LOSS RUNS TO OUR OFFICE.

INSURANCE COMPANY(NOT THE AGENCY)	POLICY NUMBER	EFFECTIVE DATE - EXPIRATION DATE	# OF LOSSES (IF ANY)	ANNUAL PREMIUM
		TO
		TO
		TO

STATE THE REASON YOU ARE APPLYING FOR A QUOTE NOW?

REMARKS:

DISCLAIMER:

This is a request for a price indication. This application does not bind the applicant nor the Company(s) to complete the insurance, but it is agreed that the information contained herein shall be the basis of the contract should a policy be issued.

FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

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YOUR FIRST AND LAST NAME:

POSITION:

DATE: