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Builder / Contractor General Liability Insurance Quote

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Personal Information
Name of Business:*
Owner's Name:*
First Last
Location Address:*
Street Address City State ZIP Code
Is the mailing address the same as the physical address?*
- Yes
- No
Mailing Address:
Street Address City State ZIP Code
Business Phone:*
Fax:
Contact Email Address:*
Business Status*
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:
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:
Loss of Income Value:
Money and Securities Value:
Glass or signs Value:
General Liability Limit:
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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Contact

Oberryman Insurance Agency

2500 Hunter Place, Suite 202
Woodbridge, Virginia 22192

Phone: (703) 986-0468

Fax: (703) 986-0752

Mon-Thu: 9:30am-5:00pm
Fri: 9:30am-4:00pm
Sat-Sun: Closed

Evening hours by appointment.

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Oberryman Insurance Agency provides auto, home, and business insurance to all of Virginia, including Woodbridge, Lorton, and Manassas.

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