About You:
* Company Name:
* First Name:
* Last Name:
* Email Address:
* Street Address:
* City:
County:
* State:
Select a State
Indiana (IN)
* Zip
* Phone Number - Day:
* Phone Number - Night:
Fax Number:
About Your Business:
* Type of Business:
Select One
Sole Proprietor
Partnership
Corporation
LLC
LLP
Association
* Do you currently have General Liability Insurance?
Select One
Yes
No
If "yes" when does your current policy expire?
If "yes" who are you currently insured with?
* Number of Owners:
* Number of Non-Owner Full-Time Employees:
* Number of Non-Owner Part-Time Employees:
* Type of Work:
Select One
Gutters, Siding & Windows Install
Carpentry (Interior)
Carpentry (Residential Const.)
Carpentry (All Other)
Carpet Installation
Concrete
Driveway & Sidewalk (Paving or Repaving)
Drywall or Wallboard Install or Repair
Electrical (inside work)
Excavation-Incl Grading of Land
General Contractor
Heat & A/C (no LP)
Janitorial Service
Landscape Gardening
Masonry
Painting (Exterior)
Painting (Interior)
Plumbing (light Comm.)
Plumbing (residential)
Roofing (residential)
Tile, Stone, Mosiac, Marble, Terrazzo
Tree Trimming
Other
* Years Business Established?
* Estimated Annual Sales (Gross): $
Estimated Annual Owner's Payroll:
$
* Estimated Annual Employee Payroll:
(Do NOT include Owner's Pay) $
* No. of Claims in last 3 years:
Select One
None
1
2
3
More Than 3
* Do you sub-out work?
Select One
Yes
No
If "Yes" What Percent?
* What Percent Residential?
* What Percent Commercial?
Amount Of Insurance Coverage:
* General Liability Insurance Amount:
$1,000,000 Per Occurrence / $2,000,000 Aggregate
$500,000 Per Occurrence / $1,000,000 Aggregate
* Medical Expense Payments (included):
$10,000 Per Person
* Fire Legal Liability (included):
$100,000
Hand Tools / Small Equipment Coverage:
* Value of Tools and Equipment:$
* Deductible Amount:
$100 Deductible
$250 Deductible
$500 Deductible
* I hereby agree to the terms and conditions .
