CONTRACTORS QUOTE APPLICATION

Business Entity is a(n)*	Association Corporation Individual Joint Venture Non-Profit Org Partnership LLC S-Corp
Doing Business As:  (Leave Blank if no Business Name)	(Only fill in if they have a Business Name)
First Name of Applicant:	*
Last Name of Applicant:	*
Location Address:	* (No PO Boxes)
City, State, Zip:	* AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA DC WV WI WY * * 5 digit
County:	*
Applicant's Phone Number:	* ex. 716-837-8804
Describe Business:	*

Enter percentage of work performed. Total must equal 100%
	Air Conditioning, Sales, Service Installation			Landscape Gardening
	- Any hoisting by crane? Yes No			- Any snow plowing? Yes No
	Carpentry - exterior			- Percent of snow plowing
	Carpentry - interior			- Any tree removal or trimming? Yes No
	Carpet Cleaning			- Any use of pesticides? Yes No
	Concrete Construction			- Percent of sprinkler installation
	- Any street or road work? Yes No			Lawnmowing
	Drywall			- Any snow plowing? Yes No
	Door / Window Installation			Masonry
	Electrical Work - within buildings			Painting - exterior
	- Is contractor licensed? Yes No			- Any Spray painting? Yes No
	Floor Covering Installation - Carpet			Painting - interior
	Floor Covering Installation - Ceramic			- Any Spray painting? Yes No
	Floor Covering Installation - Linoleum			Plastering
	Floor Covering Installation - Vinyl			- Any EIFS or Stucco work Past/Present? Yes No
	Floor Covering Installation - Wood			Plumbing - Residential
	Framing			Power Washing
	- How many homes per year?			What PSI?
	- Any hoisting by crane? Yes No			Roofing - (no hot tar)
	Heating			Sheet Metal Work
	- Any hoisting by crane? Yes No			Siding Installation
	Insulation Work - mineral, fiberglass			Sign Painting
	Janitorial Services			- Any installation? Yes No
	- Any Floor waxing? Yes No			Exterior Window Cleaning
	- Percent of waxing			- How many Stories?
	- Exterior window cleaning? Yes No
	- How many Stories for window cleaning?			Other

BUSINESS SUMMARY

Years In Business:	*
Years Experience:	*
Percent of Work Performed:
Residential :	Commercial : * Must total 100%
Inside :	Outside : * Must total 100%
New Constuction :	Remodel/Repair : *Must total 100%
Number of owners :	*
Employees:(No owners or clerical)	Full Time *  Part Time * Part Time Employees work less than 120 days per year
Total Payroll: (Do not enter commas)	*(No owners or clerical)
Annual Gross Receipts:	* (do not enter commas or dollar signs)
Are subcontractors used?:	Yes No *
If yes, what is the annual cost of subcontractors:	(do not enter commas or dollar signs)
Are Subcontractors required to maintain coverage?	Yes No
If Yes, What limits do the subs carry?
Are you involved (present or future) in new residential construction &/or development? (This would include dwellings, townhouses or condo units located in a single development):		Yes No  *
List the last 3 jobs including the cost of those jobs.
Location	Type of Job	Job Receipts
1. *	*	*
2. *	*	*
3. *	*	*
Does Risk have a Safety Program in operation?:	Yes No *
Does applicant currently have General Liability coverage? :	Yes No *
Was there past General Liability coverage? :	Yes No *
The following 6 items are required if they had prior coverage or currently have coverage.
Enter name of most recent carrier :	Policy Number
Is or was policy being cancelled or non-renewed?	Yes No (Not applicable in MO)
If yes, please explain:
Most recent Policy Premium :
Loss History: (Date of loss, Brief Desc. and Amount Paid)
If none enter NONE :

LIABILITY INFORMATION

Liability Limits 1: ($)

300/600 500/1,000 1,000/2,000 2,000/4,000

Liability Limits 2: (optional): ($)

300/600 500/1,000 1,000/2,000 2,000/4,000

PROPERTY INFORMATION

Are you requesting Building and or Contents Coverage? :	Yes No
Building Limit :	(If no building enter 0)
Contents Limit :	(do not enter commas or dollar signs)
Percent of Contents occupied as: (should add up to 100%) (Click for Help)
Office		Apartments
Storage		Shop
Construction :	Frame Joisted Masonry Masonry N/C Non-Combustible Fire Resistive
Valuation :	Actual Cash Value Replacement Cost
Property Deductible:	250 500 1000 2500 5000
Is the building 100% Sprinklered? :	Yes No
Type of Burglar alarm :	cal Central Station None
Total Square Footage of Building :
Square Footage Occupied by Insured :
Number of Stories (total Building) :
Is Basement :	Finished UnFinished No Basement
Miles to nearest body of water :
Age of Building in Years:

INLAND MARINE

Are you requesting Miscellaneous Coverages	Yes No
Additional Insured(s): How Many? :
What is their interest :
Employee Dishonesty Limit :	10,000 20,000 30,000 40,000 50,000 75,000 100,000 125,000
# of Employees :
Names and Addresses :

Comments: