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Enter information about your business, the more detailed the information the better the quote. Items with a red asterisk are required. All other item can be skipped if needed. Detail boxes will open when further explianation is needed, the pop up can be clcked to toggle off. Need help with form
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Contact Name
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First
Last
Mailing Address
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Line 1
Line 2
City
State
Zip Code
Country
Business Name
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Location Address (If different from mailing)
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Line 1
Line 2
City
State
Zip Code
Country
Email
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Business Phone
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Cell Phone
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Website
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Business Operations
Business Type
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Individual
Corporation
Limited Liability Company
Partnership
Non-Profit
Year Established
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Enter the year this business was established
Years Experience
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Enter your number of years experience in this field of work.
Are you a licensed Cotractor
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Yes
No
License Number
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Describe Operation in detail
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Employer or Tax ID Number
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Liability Limits Requested
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$1,000,000
$500,000
$300,000
$100,000
Other limit needed - Call Me
Currenlty Insured
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Yes
No
Name of Insurance Company & Expiration Date of Policy
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Any prior claims or losses
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Yes
No
List any losses within the last three years
Describe prior losses or claims
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Percentage of work residential
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Percentage of work commercial
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Percentage of New Construction
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Enter your percentage of work for both residential and commercial new construction.
Percentage of Remodeling
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Enter your percentage of work for both residential and commerical remodeling.
Number or Owners
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Enter the total number of owners, partners, members or officers
Owners Payroll
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Enter total annual payroll for all owners
Number of Employees
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Enter only W2 employees do not count any 1099 paid employees.
Employee Payroll
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Enter total annual payroll for all W2 employees
Do you use sub contractors
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Yes
No
Insured Sub Cost
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Total annual payroll of insured subs. Most companies count labor and material.
Uninsured Sub Cost
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Total annual payroll of all uninsured subs. Most companies count labor and material.
Check all items that pertain to your subs
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Sub must be insured
My company is listed as additional insured on subs insurance
Sub signs hold harmless agreement with my company
Some of my subs are uninsured
All of my subs are uninsured
Check all items that pertain to your work
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New Home Construction
Remodeling Only
New or Re-Roofing
Roofing in association with room additions only
Check the category that best describes your work
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General Contractor
Remodeling Contractor
Handyman
Painting Interior & Exterior
Plumbing
Electrical work within buildings
HVAC
Roofer
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