| Name of Business: |
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| Address: |
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| Contact Name and Phone Number: |
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| Web Site: |
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| Email Address: |
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| Years in Business: |
mm/dd/yyyy |
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| Property Information: (Provide for
Each Location Insured) |
| Policy Effective
Date
mm/dd/yyyy |
| |
Location 1 |
Location 2 |
Location 3 |
| Location Address: |
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| Building Limit: |
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| Contents Limit: |
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| Construction Type: |
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| Square Footage: |
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| Year Built: |
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| Year of Remodeling: |
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| Other Occupancies: |
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| *Inland Marine |
| Policy Effective
Date
mm/dd/yyyy |
| Please list a schedule of equipment
you'd like to insure: |
|
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| How many jobs a year do you do? |
Commercial:
|
Residential:
|
| What is the job size:
Smallest: $
Largest: $
|
| |
| *General Liability: Policy
Effective Date
mm/dd/yyyy |
| 1. What type of electrical work do you
do? |
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| 2. Total Gross Annual Sales: $
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| 3. What is your total Field Payroll (not clerical or sales people): |
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Break it
down as follows: |
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| Wiring of Buildings:
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| Street or Traffic Lights:
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| Machinery:
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| Interior of offices for computers
and phones:
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| Fire or Burglar Alarms:
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| Other:
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| Do you Use Subs?
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If so, what do they do?
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| Total w/ annual cost of subs:
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| Who supervises the subs on the jobsite, and how often does that occur? |
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| Do you require certificates of insurance from all subs?
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| CGL Limits required: |
Occurrence:
$ |
Aggregate:
$ |
| Do you require subs to sign written construction contracts containing indemnity / hold harmless clauses in your favor?
|
| Do you monitor subs to make sure
that they are in standard markets that provide full GL coverage
including contractual liability?
|
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| *Automobile: Policy Effective Date
mm/dd/yyyy |
| From your current policy, list the schedules of
automobiles to insure.
It should include VIN #’s, comprehensive and collision deductibles, etc.
|
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| *Umbrella: Policy Effective
Date
mm/dd/yyyy |
| What limit would you like us to quote? |
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| 4 years of
loss history will be required prior to binding
coverage. |
