On-Line Contractor General Liability Quote Form One Simple Form - takes only 2-3 Minutes! Your Name: BUSINESS Name: Mailing Address: City: State: (Must be Pennsylvania) Zip/Postal: E-Mail (REQUIRED): E-Mail again for accuracy: Phone: Fax (optional):   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   Comments/Remarks:   Send my quotation via: E-Mail Fax Regular Mail Please Call Me! Thank you for filling out this form COMPLETELY! We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release them from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy. Yes, I Agree. Please Send Me a Quote NOW! Click Button Below When Done Please Click Only Once . . . May take up to 30 seconds!
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