Artisan Contractor Quote Request

Complete the following information if you would like to obtain an Artisan Contractor Insurance quote. Please understand this is not an application. An application will be sent to you if coverage is desired.
All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.
Personal Information
What is your name?
Last
First
Middle
What is your business name?
Business Name
What is your address?
Street
City
State
Zip
What is your telephone number?
Home
Business
What is your fax number?
Fax
What is your email address?
Email
Underwriting Information
How many owners?
Number of Owners
How many employees?
Number of Employees
What is the payroll amount of the owners?
Payroll of Owners
What is the payroll amount of the employees?
Payroll of Employees
What is the total annual gross?
Total Annual Gross Receipts
What are the annual sub costs?
Total Annual Sub Costs
What is your classification?
Classification
What is your contractors license number?
Contractors License Number
What is the license type?
License Type
Years of experience in this business?
Years of Experience
How many years have you operated under your current business name?
Years Operated Under Current Name
Have you used any other business names during the past 5 years?
Other Business Names
 Yes No
Have you been involved in the original construction or remodeling of town homes, condos, row homes or developments of 15 or more unattached single family dwellings during the past 5 years?
Construction or Remodeling
 Yes No
Do you construct footings or foundations which may support dwellings or other structures?
Construct Foundations
 Yes No
Do you construct slab or monolithic floors?
Construct Floors
 Yes No
Do you construct piers or underpinning which may support dwellings or other structures?
Construct Piers
 Yes No
Do you construct retaining walls which may support dwellings or other structures?
Retaining Walls
Do you construct fireplaces or chimneys?
Fireplaces or Chimneys
What is the percentage of work done as a General Contractor?
Percentage as General Contractor
What is the percentage of work done as a Sub-Contractor?
Percentage as Sub-Contractor
What is the percentage of work done on Residential?
Percentage on Residential
What is the percentage of work done on Commercial?
Percentage on Commercial
What is the percentage of work done for Remodeling?
Percentage on Remodeling
What is the percentage of work done for Renovation?
Percentage for Renovation
What is the percentage of work done for Repair or Maintenance?
Percentage for Repair or Maintenance
Claims Information
Were there any losses or claims in the last 5 years?
Losses - Claims
 Yes No
If yes, what is the date, amount paid and description of each loss or claim?
Coverage Information
What is the current insurance company?
How much are you paying now?
Amount Current Coverage
What is the liability limit requested?
Liability Limit
What is the loss of income requested?
Loss of Income Coverage
Are there any questions, comments or additional coverage required?
Questions, Comments or Additional Coverage
What is 5+12?
(Are you human?)
Please Note: Insurance coverage cannot be bound without a written binder from our office.