631ContractorsInsurance.com
General Liability Insurance Quote Fax Form
Please fill print and fill out this form and
fax to 866-542-6687 ext 467
Your Name: ____________________________
BUSINESS Name: ____________________________
Mailing Address: ____________________________
City: __________________
State:
New York
Zip/Postal: ___________
E-Mail (REQUIRED): ___________________________
Phone: ___________________________
Fax (optional): ________________________
 
Business Underwriting Information
Type of operation: _________________________
Describe operations in detail: _____________________________________
License class: _____________________________________
License Number: _____________________________________
Social Sec. or Employer ID#: _____________________________________
 
Limit of Liability
Coverage Requested?		 $300,000
$500,000
$1 Million
 
Currently Insured? Yes No
Name of Carrier & how long insured? _________________________________________
Prior Claims? Yes No
Describe claims in detail: _________________________________________
 
Years in business: ____________________
Years experience in field: __________________________________________
Percentage of work residential: __________________________________________
Percentage of work commercial: __________________________________________
 
Number of Active Owners: __________________________________________
Number of Employees: 0   1   2   3+
Annual Employee Payroll: $ __________________________________________
Annual Gross Sales: $ __________________________________________
 
Do you subcontract work? Yes No
(If yes, what percentage of your work
is subbed, and what kind of work?) 		_______________________________________
Do you do foundation work? Yes No
Do you work on condos? Yes No
Employees paid over $18/hour? Yes No
Do you have a safety program? Yes No

 
Comments/Remarks: __________________________________________
  __________________________________________
Send my quotation via: E-Mail Fax
Regular Mail
Please Call Me!

 

Thank you for filling out this form

Please Note: Insurance coverage cannot be bound without a written binder from our office. We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release them from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

Yes, I Agree. Please Send Me a Quote NOW!