Applicant’s Name:

First Last

Mailing Address:

Location Address:

Is applicant properly licensed where required by law?

Yes

No

License Number

Number of active owners/officers/partners:

Number of Employees

Estimated annual:

Payroll (excl. owner)

Receipts

Subs Costs

Does applicant carry Workers’ Compensation coverage on temporary employees?

Yes

No

Does applicant lease employees from others?

Yes

No

If yes, please provide payroll. $

Does applicant subcontract work to others?

If yes, are certificates of insurance required?

Do subcontractors name the applicant an additional insured?

Prior Policy

Prior Policy Date

_______ to ________

Carrier Name

Coverage Type: Liab/PHD/MTC

POLICY #

# of Units Insured

Any loses within the past 5 years?

If YES please upload on the related documents attaching box below.

Amount Paid

Driver Involved in Loss

Upload Your Current Insurance Policy or Related Documents

Drop files here or

Max. file size: 20 MB, Max. files: 10.

List subcontractor trades used with costs and percentage of operations

List equipment owned or leased

Please detail any “yes” answers to the following questions below.

Prior Policy

Recents Articles

The Importance of Long-Term Care Insurance in Future Planning

Why Health Insurance is Essential for Every Business Owner and Their Employees

April Insurance Agency

Get A Quote

Helpful Links

For Clients

Tree Trimming Insurance Quote

List subcontractor trades used with costs and percentage of operations

List equipment owned or leased

Please detail any “yes” answers to the following questions below.

Prior Policy

Recents Articles

The Importance of Long-Term Care Insurance in Future Planning

Why Health Insurance is Essential for Every Business Owner and Their Employees

April Insurance Agency

Get A Quote

Helpful Links

For Clients