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PENNSYLVANIA & NEW JERSEY:
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    On-Line Contractor
    General Liability Quote Form
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    Your Name:
    BUSINESS Name:
    Mailing Address:
    City:
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    Zip/Postal:
    E-Mail (REQUIRED):
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    Phone:
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    Business Underwriting Information
    Type of operation:
    Describe operations in detail:
    License class:
    License Number:
     
    Limit of Liability
    Coverage Requested?    		 $300,000
    $500,000
    $1 Million
     
    Currently Insured? Yes No
    Name of Carrier & how long insured?
    Prior Claims? Yes No
    Describe claims in detail:
     
    Years in business:
    Years experience in field:
    Percentage of work residential:
    Percentage of work commercial:
     
    Number of Active Owners:
    Number of Employees: 0   1   2   3+
    Annual Employee Payroll: $
    Annual Gross Sales: $
     
    Do you subcontract work? Yes No
    (If yes, what percentage of your work
    is subbed, and what kind of work?)
    Do you do foundation work? Yes No
    Do you work on condos? Yes No
    Employees paid over $18/hour? Yes No
    Do you have a safety program? Yes No

     
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    505 Old York Road, Suite 105 - Jenkintown, PA 19046    (Click for Map/Directions)
    Phone: 215-254-7200    |    Fax: 215-572-7192    |    Privacy Notice/Copyright Info.
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