BUILDER/CONTRACTOR GENERAL LIABILITY INSURANCE QUOTE
We would like to provide you with a free, no-obligation general liability insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.
General Information
Name of Business:
Owner's Name:
Location Address:
City:
State:
Zip:
Is the mailing address the same as the location address?
Y
N
Mailing Address:
City:
State:
Zip:
Business Phone:
Fax:
Contact Email Address:
Business Status:
Years in Business:
# Emp:
Business Tax ID Number:
Website Address:
Been insured w/ Erie Insurance?:
Yes
State(s) conducting business in?:
How Did You Hear About Us?
Please check all that apply:
Search Engine
Social Network
Advertisement
Family or Friend
Forum/Blog
Co-Worker
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 Any Other Previous Carriers Over the Past 3 Years Below:
Carrier Name:
Premium: $
Carrier Name:
Premium: $
Property Questions
Age of building /Year Built:
Type of building construction:
Number of stories:
Other occupancies:
Square feet you occupy:
sq. ft.
If the building is over 25 years old, please answer the following:
Year Electricity was updated:
Is it on circuit breakers?:
Yes
Year Plumbing was updated:
Copper or Galvanized plumbing?:
Copper
Galvanized
Other:
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 long in business
How many locations
Estimated Annual Payroll
years
$
Please give a brief description of your business(below):
Coverage Limits
Building:
Contents (inventory, supplies, etc.):
Computers & Equipment:
Deductible:
Loss of Income:
$
$
$
$
Money and Securities:
Glass or signs:
General Liability Limit:
Non-owned and Hired Automobile Liability:
Is liquor liability needed?
$
$
$
Yes
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 %
Remodel/Additions %
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
Have you ever been named in litigation regarding faulty construction?:
Yes
Are there any claims or legal actions pending?:
Yes
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
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.
