Questionnaire

Please fill out the following form to get a FREE Insurance Quote!! It is important that you fill out every field. If you have any questions, please feel free to give us a call at (602) 242-2222.

I would like to receive a quote on:
General Liability
Worker's Compensation
Health and Medical

Describe your largest project including dollar amount.
First Name:		Last Name:
Company Name:		Company Type:
Mailing Address:		Mailing City:	Zip:
Physical Address:		Physical City:	Zip:
Best Phone Number:		Alternate Phone Number:
Email Address:
EIN:		License Number:
License Type:		Yrs in Business:	Yrs of Exp.:
Do you perform structural work?	YES NO	Remodeling/Repair?	YES NO % Remodel/Repair
New Construction?	YES NO % New Construction	Residential?	YES NO % Residential
Commercial?	YES NO % Commercial
Maximum Number of Stories:		Max Depth Below Grade:
Total Gross Receipts (this year):		Subcontractor Costs:
How many projects did you start last year?		How many of those projects did you complete?
Total Payroll (exclude owner):		Number of Employees (not owners):
Has any licensing authority taken action against you, your company or any affiliates?			YES NO
Have you allowed or will allow your license to be used by any other contractor?			YES NO
Has any lawsuit ever been filed, or any claim otherwise been made against your company of any partnership or joint venture of which you have been a member of your company's predecessors in business, or against any person, company or entities on whose behalf your company has assumed liability?			YES NO
Is your company aware of any facts, circumstances, incidents, situations, damages or accidents (including but not limited to: faulty or defective workmanship, product failure, construction dispute, property damage or construction worker injury) that a reasonably prudent person might expect to give rise to a claim or lawsuit, whether valid or not, which might directly or indirectly involve the company?			YES NO
Do you use subcontractors?			YES NO
How would you like to pay for your policy?			Monthly Financing Pay in Full
WE WILL NOT BE ABLE TO GIVE YOU A QUOTE WITHOUT ALL INFORMATION FILLED OUT!! I verify that all information above is accurate to the best of my knowledge and agree to the Privacy Policy.