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Builder / Contractor General Liability Insurance Quote
Call Us Today
(703) 986-0468
Builder / Contractor General Liability Insurance Quote
Step
1
of
11
9%
Personal Information
Name of Business:
*
Owner's Name:
*
First
Last
Location Address:
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Is the mailing address the same as the physical address?
*
Yes
No
Mailing Address:
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Business Phone:
*
Fax:
Contact Email Address:
*
Business Status
*
Select
LLC
Individual
Corporation
Partnership
Joint Venture
Years in Business:
*
# of Employees:
*
Business Tax ID Number:
*
Website Address:
Been insured w/ Erie Insurance?
Yes
No
State(s) conducting business in?
*
How Did You Hear About Us?
Please check all that apply:
Search Engine
Social Network
Forum/Blog
Advertisement
Family or Friend
Coworker
Other
Other:
Current Insurance Information
Please provide information on previous insurance carrier:
Previous Ins. Carrier:
Policy number:
Prior premium:
Policy renewal date:
Please provide information about your business:
Years in business:
Projected Gross annual receipts:
Projected annual payroll:
Describe your business, product or service:
What type of coverages do you currently have:
Bond
Commercial Auto
Commercial Liability
Commercial Property
Commercial Umbrella
Directors & Officers Liability
Disability
Group Health
Group Life
Professional Liability
Other
Please list your other coverages:
Please List Any Other Previous Carriers Over the Past 3 Years Below:
Carrier Name:
Premium: $
Property Questions
Age of building /Year Built:
Type of building construction:
Select One
Frame
Stucco
Masonry/Brick
Fire Resistive
Other
Number of stories:
Other occupancies:
Square feet you occupy:
Is your building over 25 years of age?
Yes
No
Year Electricity was updated:
Is it on circuit breakers?
Yes
No
Year Plumbing was updated:
Copper or Galvanized plumbing?:
Copper
Galvanized
Year Building was last re-roofed:
Type of roofing material:
Type of heating system in the building:
About Your Business
# of full-time employees
# of part-time employees
How many years have you been in business?
How many locations
Estimated Annual Payroll
Please give a brief description of your business (below):
Coverage Limits
Building Value (if any):
Contents Value (inventory, supplies, etc.):
Computers & Equipment Value:
Deductible:
Select One
$100
$250
$500
$1000
Loss of Income Value:
Money and Securities Value:
Glass or signs Value:
General Liability Limit:
Select One
$1,000,000
$2,000,000
$3,000,000
$4,000,000
Non-owned and Hired Automobile Liability:
Yes
No
Is liquor liability needed?
Yes
No
If Glass Coverage is needed, please provide dimensions:
Please list other coverages you may need:
Project/Work Information
Please write a Description of Operations below:
What % of your work is:
(each line must total 100%)
Commercial
Industrial
Residential
New Construction
Subcontractor
What % of your work is as a:
General Contractor:
Subcontractor:
What % of your work is:
Subcontracted Out:
Sub Costs: $
Do you collect certificates of insurance at a $1 million limit?
Yes
No
Receipts / Payroll / Dollar Value Info
Gross receipts for the past 3 years and the next 12 months:
(3rd yr prior) $
(2nd yr prior) $
(Last 12 mths) $
(Next 12 mths) $
# of owners/officers/partners active at the job site or supervising:
Payroll of employees (excl. owners, officers, partners & clerical):
Payroll of Officers:
$ value of avg. job completed incl. materials, labor, equipment:
Describe any project(s) underway or planned for the next year, including values below:
Miscellaneous and Legal Info
Have you ever performed ground up construction involving condominiums, townhouses, apartments, or single family tract developments of two (2) or more?:
Yes
No
Have you ever been named in litigation regarding faulty construction?:
Yes
No
Are there any claims or legal actions pending?:
Yes
No
Do any of the entities named in the application have knowledge of any pre-existing act, omission, event, condition or damages to any person or property that may potentially give rise to any future claim or legal action against any such entity?:
Yes
No
Claims History
Enter all claims or occurrences that may give rise to claims for the prior 3 years. This information is kept strictly confidential.
Claim #1
Claim Status:
Closed
Open
Date of Occurrence:
Date of Claim:
Type/Description of Occurrence or Claim:
Amount paid on your behalf:
Amount reserved on behalf:
Claim #2
Claim Status:
Closed
Open
Date of Occurrence:
Date of Claim:
Type/Description of Occurrence or Claim:
Amount paid on your behalf:
Amount reserved on behalf:
Additional Comments
Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough space, please enter them here.
Please click on the
"Submit Quote"
button to send your quote request. One of our representatives will respond to your submission as soon as possible.
Email
This field is for validation purposes and should be left unchanged.
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