Quote General Contractor 1 Contact2 Coverage options3 Roofers4 Underwriting5 Contractor General Liability Insurance QuotePlease note! In some instances we will send you a supplemental application depending on your responses. Requested need by Date Date Format: DD slash MM slash YYYY Expiration Date of expiring policy if applicable Date Format: DD slash MM slash YYYY Are you using this form as a prospective client or for the renewal of an existing client?* Existing Client for renewal quoting New prospective Client (we do not have a policy with you now) Name of Person completing this form if different that First named insuredCompany NameIf the company is your legal name insert your legal nameFist Named Insured First Last The "primary" and official person of contact to receive all legal notices. The ultimate person responsible for all insurance making decisions for the company / entity. Contractor License Number(s)Mailing Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code GENERAL LIABILITY COVERAGEAre ISO forms required? Yes No I am not sure Coverage limitsPlease Select$500,000 each occurrence / $500,000 Aggregate / $500,000 completed operations$500,000 each occurrence / $1,000,000 Aggregate / $5000,000 completed operations$1,000,000 each occurrence / $2,000,000 Aggregate / $1,000,000 completed operations$1,000,000 each occurrence / $2,000,000 Aggregate / $2,000,000 completed operationsBase limits. If higher limits are required select the highest limits here and then answer the following question under "Excess Limits"Excess limitsPlease selectNone requiredThird Choice$1,000,000$2,000,000$3,000,000$4,000,000$5,000,000$10,000,000$20,000,000Higher excess limitsSpecify Excess limitMedicalPlease selecdt$5,000$10,000Fire legal liabilityPlease select$50,000$100,000DeductiblePlease Select$1,000$2,500$5,000$10,000$20,000$30,000$50,000Total "projected" Gross receipt for the next 12 monthsTotal "projected" Subcontractor Costs for the next 12 monthsTotal Projected "direct" employee payroll for the next 12 monthsTotal Owner's projected payroll or draw for the next 12 monthsTotal years in businessTotal Years ExperienceLoss HistoryPlease selectIn business 5+ years with NO lossesIn business 3+ years with NO lossesIn business under 3 years with NO lossesHave losses in last 5 years (must submit loss runs)Loss runs may be emailed to insurance@athenainsurance.com or uploaded with this form. Use the file format of .pdf please. loss runs file upload Drop files here or Accepted file types: pdf. If you have more than five losses in the past five years please email loss runs to steve@athenainsurance.comCLASSES OF BUSINESSSelect the classes of business to "include" in your operations. It is highly recommended that you select "all" that apply. If you only perform services in on class there is not a need to complete all classes. 1st classPlease selectCarpentry Interior/Cabinet InstallationCarpentry FramingCarpet CleaningCleaning Outside the BuildingCommercial Equipment InstallationConcrete FoundationConcrete Flat WorkConcrete Pumping (excludes Boom Pumps)Concrete Pumping Including Boom PumpsDebris RemovalDoor & Window Installation/GlazersDrywallElectricalExcavationFencingFloor CoveringFurnishing InstallaionGeneral Contractor Commercial New ConstructionGeneral Contractor Commercial remodelGeneral Contractor Residential New ConstructionGeneral Contractor Residential RemodelGradingGunitingHome Furnishings Installation / Interior DecoratorsHVAC / Heating and AirInsulationJanitorialLandscapeMasonryMetal Erection - Decorative/Sheet metalMetal Erection - StructuralPainting - InteriorPainting - ExteriorPaper HangerPlastingPlumbingPower Washing/Sand BlastingRefrigeration Systems & EquipmentRoofer CommercialRoofer ResidentialSeptic Tank Install, Service or RepairSiding / DeckingSign Erection, Install or RepairSolar Energy ContractorsStreet CleaningStreet or Road Paving or RepavingSwimming Pool CleaningSwimming Pool InstallationTile or MarbleTree Trimming or RemovaloWindow Cleaning1st % amountPlease enter a number from 1 to 100.2nd classPlease selectCarpentry Interior/Cabinet InstallationCarpentry FramingCarpet CleaningCleaning Outside the BuildingCommercial Equipment InstallationConcrete FoundationConcrete Flat WorkConcrete Pumping (excludes Boom Pumps)Concrete Pumping Including Boom PumpsDebris RemovalDoor & Window Installation/GlazersDrywallElectricalExcavationFencingFloor CoveringFurnishing InstallaionGeneral Contractor Commercial New ConstructionGeneral Contractor Commercial remodelGeneral Contractor Residential New ConstructionGeneral Contractor Residential RemodelGradingGunitingHome Furnishings Installation / Interior DecoratorsHVAC / Heating and AirInsulationJanitorialLandscapeMasonryMetal Erection - Decorative/Sheet metalMetal Erection - StructuralPainting - InteriorPainting - ExteriorPaper HangerPlastingPlumbingPower Washing/Sand BlastingRefrigeration Systems & EquipmentRoofer CommercialRoofer ResidentialSeptic Tank Install, Service or RepairSiding / DeckingSign Erection, Install or RepairSolar Energy ContractorsStreet CleaningStreet or Road Paving or RepavingSwimming Pool CleaningSwimming Pool InstallationTile or MarbleTree Trimming or RemovaloWindow Cleaning2nd % amountPlease enter a number from 1 to 100.3rd classPlease selectCarpentry Interior/Cabinet InstallationCarpentry FramingCarpet CleaningCleaning Outside the BuildingCommercial Equipment InstallationConcrete FoundationConcrete Flat WorkConcrete Pumping (excludes Boom Pumps)Concrete Pumping Including Boom PumpsDebris RemovalDoor & Window Installation/GlazersDrywallElectricalExcavationFencingFloor CoveringFurnishing InstallaionGeneral Contractor Commercial New ConstructionGeneral Contractor Commercial remodelGeneral Contractor Residential New ConstructionGeneral Contractor Residential RemodelGradingGunitingHome Furnishings Installation / Interior DecoratorsHVAC / Heating and AirInsulationJanitorialLandscapeMasonryMetal Erection - Decorative/Sheet metalMetal Erection - StructuralPainting - InteriorPainting - ExteriorPaper HangerPlastingPlumbingPower Washing/Sand BlastingRefrigeration Systems & EquipmentRoofer CommercialRoofer ResidentialSeptic Tank Install, Service or RepairSiding / DeckingSign Erection, Install or RepairSolar Energy ContractorsStreet CleaningStreet or Road Paving or RepavingSwimming Pool CleaningSwimming Pool InstallationTile or MarbleTree Trimming or RemovaloWindow Cleaning3rd % amountPlease enter a number from 1 to 100.4th classPlease selectCarpentry Interior/Cabinet InstallationCarpentry FramingCarpet CleaningCleaning Outside the BuildingCommercial Equipment InstallationConcrete FoundationConcrete Flat WorkConcrete Pumping (excludes Boom Pumps)Concrete Pumping Including Boom PumpsDebris RemovalDoor & Window Installation/GlazersDrywallElectricalExcavationFencingFloor CoveringFurnishing InstallaionGeneral Contractor Commercial New ConstructionGeneral Contractor Commercial remodelGeneral Contractor Residential New ConstructionGeneral Contractor Residential RemodelGradingGunitingHome Furnishings Installation / Interior DecoratorsHVAC / Heating and AirInsulationJanitorialLandscapeMasonryMetal Erection - Decorative/Sheet metalMetal Erection - StructuralPainting - InteriorPainting - ExteriorPaper HangerPlastingPlumbingPower Washing/Sand BlastingRefrigeration Systems & EquipmentRoofer CommercialRoofer ResidentialSeptic Tank Install, Service or RepairSiding / DeckingSign Erection, Install or RepairSolar Energy ContractorsStreet CleaningStreet or Road Paving or RepavingSwimming Pool CleaningSwimming Pool InstallationTile or MarbleTree Trimming or RemovaloWindow Cleaning4th % amountPlease enter a number from 1 to 100.5st classPlease selectCarpentry Interior/Cabinet InstallationCarpentry FramingCarpet CleaningCleaning Outside the BuildingCommercial Equipment InstallationConcrete FoundationConcrete Flat WorkConcrete Pumping (excludes Boom Pumps)Concrete Pumping Including Boom PumpsDebris RemovalDoor & Window Installation/GlazersDrywallElectricalExcavationFencingFloor CoveringFurnishing InstallaionGeneral Contractor Commercial New ConstructionGeneral Contractor Commercial remodelGeneral Contractor Residential New ConstructionGeneral Contractor Residential RemodelGradingGunitingHome Furnishings Installation / Interior DecoratorsHVAC / Heating and AirInsulationJanitorialLandscapeMasonryMetal Erection - Decorative/Sheet metalMetal Erection - StructuralPainting - InteriorPainting - ExteriorPaper HangerPlastingPlumbingPower Washing/Sand BlastingRefrigeration Systems & EquipmentRoofer CommercialRoofer ResidentialSeptic Tank Install, Service or RepairSiding / DeckingSign Erection, Install or RepairSolar Energy ContractorsStreet CleaningStreet or Road Paving or RepavingSwimming Pool CleaningSwimming Pool InstallationTile or MarbleTree Trimming or RemovaloWindow Cleaning5th % amountPlease enter a number from 1 to 100.Total must equal 100%Do you do any new "commercial" construction? Yes No Do you do any new "residential" construction? Yes No Are you doing any demolition work? Yes No Are you doing any trash hauling other than from a construction site? Yes No Are you performing any Earthquake retrofitting or updating? Yes No Are you involved or doing Earth Bearing Retaining wall construction over "3" feet in height? Yes No ADDITIONAL COVERAGE OPTIONSEmployee Benefits Liability Employee Benefits Liability Removal of Prior Works Exclusion for (if available) Small Tools Coverage Heavy Equipment Coverage Contractor's Pollution Liability ENDORSEMENTSBlanket Additional Insured Yes No Need help and consulting It is recommended that if you have 5 or more to select this option. "Yes"Blanket Ongoing Operations with Primary Wording Yes No Need help and consulting It is recommended that if you have 5 or more to select this option. "Yes"Blanket Waiver of Subrogation Yes No Need help and consulting It is recommended that if you have 5 or more to select this option. "Yes"Blanket Completed Operations Yes No Need help and consulting It is recommended that if you have 5 or more to select this option. "Yes"Exterior Insulation and Finish Systems Yes No Need help and consulting Many policies exclude this. Check "yes" if you want to buy this coverageUninsured Subcontractor Contractor Coverage Yes No Need help and consulting Many policies exclude this. Check "yes" if you want to buy this coverageCondo/Townhome Remodel Yes No Need help and consulting Many policies exclude this. Check "yes" if you want to buy this coverageDefense Cost Outside Limits endorsement Yes No Need help and consulting Note, specific language of this endorsement "will" vary from company to company. In essence it is not placed within the limits of liability coverage. INDIVIDUAL ENDORSEMENTSEstimate how many additional insured over the next 12 monthsPlease select1-45-99-1516-2526-50 ROOFERS OPTIONAL ENDORSEMENTSOpen Roof and Hot Work Buyback coverage Not applicable due to no roofing operations Yes - Full limit Yes - 50% sub-limit No I would like to know the price difference I would like to know what it covers Check all that apply UNDERWRITING INFORMATIONHave you had "any" losses in the last 5 years? Yes No Provide date of loss, type of loss, amount paid out and specify if claim is closedNumber of Field Employees (exclude owners, partners & officers)Gross receipt for the last 12 monthsList States in which you operateDetailed description of operationsESTIMATED PERCENTAGE OF WORK PERFORMED "Residential vs Commercial"ResidentialCommercialHOW MUCH IS DONE BETWEEN THE FOLLOWING THREE CHOICESESTIMATE A PERCENTAGENew Construction ground upRemodeling/Repair/ServiceTract Subdivison wokrDescribe the largest project in the last 5 years along with the gross $receiptsHave you been involved or do you subcontract any work involving blasting operations, hazardous waste, asbestos, mold, PCB's, or medical and/or industrial? Yes No OPERATING PROCEDURESDo you operate your business under more than one name? Yes No Other Business Name or namesDo you own or operate any other business? Yes No Please provide detailsHas any licensing authority taken any action again you, your company or any affiliates? Yes No Describe actions, entity and detailsHave you allowed or will you 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 Please explain details of lawsuit or claimIs 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 Please explain in detail the facts as you know them. SUBCONTRACTORSDo you use subcontractors? Yes No Do you do any work for condominium or townhouse "associations"? Yes No Do you do any OCIP (Wrap-up) work? Yes No Do you do any work performed for a fee or with labor and/or materials costs paid by others? Yes No SUPPLEMENTAL QUESTIONSDo you have a project in progress for which you are seeking coverage under this quote? Yes No Please describe the details of the project, name, cost, subcontracted costs, lengthLitigation against your customers. Within the past 4 years have you filed any lawsuits and/or arbitration actions against any of your customers for nonpayment of your services and/or materials you supplied? Yes No Share this:TwitterFacebookLike this:Like Loading...
