Contractors Quote Form

Contractors Insurance Quote Form

Contractors Package
Quote Form

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- Allow up to 2 weeks to receive a quotation

GENERAL INFORMATION

Business Name:		Phone:
Mailing Address:		Contact:
City:	State: Zip:	Fax:
Type of Entity:	C Corp S Corp Partnership Individual LLC Other:	Email:
Year Business Established:	Years Experience in Field:	Quote Need by Date:
Federal ID # (FEIN):

Business Description:
If a new business list experience:

POLICY INFORMATION

Current Carrier: Expiration Date: Current Premium:
(Not Agency) State "NONE" if no current coverage.

PREMISES # 1 INFORMATION
NOTE: Building Owners & Tenants must complete the below information if any Property is to be covered.

Location # 1: Address, City, State, Zip:

Occupancy (Ex: Office, Store, Shop): Other Tenants Occupancies:

Bldg. Construction: # Stories: Approx. Square Feet You Occupy: % of Bldg You Occupy:

Year Built: Is Building Stand Alone or Connected to Buildings? Stand Alone..Connected # of Apartments?

Updates to Bldg (Year): Electrical Plumbing Heating/AC Roof or All Within 10 Years?Y..N

PROPERTY PROTECTION
Burglar Alarm:Y..N Fire Alarm:Y..N Are Alarms connected to Police/Fire or Monitored?Y..N

Fire Department within 5 miles?Y..N Fire Hydrant w/in 1,000 Feet?Y..N Is Building Sprinklered?Y..N

PREMISES #1 LIMITS OF INSURANCE

BUILDING LIMIT: Replacement Cost...or...Actual Cash Value Deductible

CONTENTS LIMIT: Replacement Cost...or...Actual Cash Value Deductible

CONTRACTORS TOOL/EQUIP. FLOATER: Misc. Total Value: Scheduled Total Value:
(Total All Items less than $2,000 each) (Total All Items greater than $2,000 each)

Other Coverages & Limits:

PREMISES #2 INFORMATION
If only one (1) premises, please scroll down to Liability Information & Limits Section

Location # 2: Address, City, State, Zip:

Occupancy (Ex: Office, Store, Shop): Other Tenants Occupancies:

Bldg. Construction: # Stories: Approx. Square Feet You Occupy: % of Bldg You Occupy:

Year Built: Is Building Stand Alone or Connected to Buildings:Stand Alone..Connected # of Apartments?

Updates to Bldg (Year): Electrical Plumbing Heating/AC Roof or All Within 10 Years?Y..N

PROPERTY PROTECTION
Burglar Alarm:Y..N Fire Alarm:Y..N Are Alarms connected to Police/Fire or Monitored?Y..N

Fire Department within 5 miles?Y..N Fire Hydrant w/in 1,000 Feet?Y..N Is Building Sprinklered?Y..N

PREMISES #2, LIMITS OF INSURANCE

BUILDING LIMIT: Replacement Cost...or...Actual Cash Value Deductible

CONTENTS LIMIT: Replacement Cost...or...Actual Cash Value Deductible

Other Coverages & Limits:

LIABILITY INFORMATION & LIMITS

LIABILITY OCCURRENCE LIMIT:
UMBRELLA LIMIT OPTION (Only Applicable if $1,000,000 is carried on above Limit):

# of Owners / Officers: Total # of Laborer Employees: (Do not include office / clerical employees)

% of Work Subcontracted: Type of Work Subcontracted:
Do you obtain Certificates of Insurance from subcontractors:Y..N

List Class of Operations (ie: Carpentry, Drywall, Heating/AC, Painting, Electrical, etc...)	# of Employees	Payroll (Annual)

LOSS INFORMATION - Past 5 Years

Date of Loss	Description of Loss - Enter "NONE" in Description Line below if no losses.	Amount Paid

ADDITIONAL COMMENTS / INFORMATION

The above information is correct to the best of my knowledge. Check: Initials:

   WOULD ALSO LIKE A QUOTE FOR:
   AUTO - Quote Form is available on our site. "COMMERCIAL AUTO Quote Form"
   WORKERS COMP - Quote Form is available on our site.  "WORKERS COMPENSATION"
   UMBRELLA

QUESTIONS / HELP	Contact Pittsburgh Office
Phone:	(412) 271-8888 (9AM - 4:30PM EST)
Fax:	(412) 271-8898
Email:	insurance@thompsongusic.com