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ARG & Associates will provide you with a free, no-obligation Home and Earthquake Insurance quote. The information below is kept confidential. Please answer as many questions as possible, so we can provide you with the most accurate quote.

Contractor Liability Insurance

Company Information

Company Name:                    Date:

Contact:

Address:

City:

State:

Zip:

Phone:                                Best time to call:   am    pm

Fax:

E-mail:

Insurance Information

Currently Insured with:

Policy Number:            Policy Expiration Date:

Premium Amount: $       Insured Amount: $

Term of Insurance:  6 months    1 year    other:

What other types of insurance coverage do you have relating to your business? (Please list below):

Insurance Type                              Premium paid per Year                      Expiration Date

Business Liability                         $

Business Auto                             $

Business Umbrella                       $

Workers' Compensation                $

Professional Liability                     $

Liability for Corporate Executives   $

Group Health                               $

Group Life                                   $

Group Retirement/401k/etc.          $

Surety Bonds                              $

Other:           $

Company Financial Information

What was your past years Annual Income: $    Projected Current Year: $

Cash: $           Securities: $    Other income: $

Amount of inventory:  $

Amount of Supplies:  $

Amount of Equipment: $

Amount of other Assets: $

What was your past years Annual Payroll: $   Projected Current Year: $

How many years has the company been in business?

How many Full Time employees do you employ?

How many Part Time employees do you employ?

Do you have any contract labor?  Yes    No, if yes, how many contractors do you have?

Please describe your business below:

Project/s Information

1st Project

Address:       City:      State:      Zip:

Estimated Project Start Date:      Estimated Completion Date:

In the space provided below please give a detailed description of the project or you portion of the project:

2nd Project

Address:       City:      State:      Zip:

Estimated Project Start Date:      Estimated Completion Date:

In the space provided below please give a detailed description of the project or you portion of the project:

3rd Project

Address:       City:      State:      Zip:

Estimated Project Start Date:      Estimated Completion Date:

In the space provided below please give a detailed description of the project or you portion of the project:

Claims Information

Has a claim been filed in the past 5 years? Yes No, if yes, please answer the questions below for each claim.

1st Claim

Name of Claimant:      Date of Claim:

Address of Claim:        City:      State:

Please list details about the Claim below:

Is the Claim  Open or  Closed?

Amount Paid on Claim: $

2nd Claim

Name of Claimant:      Date of Claim:

Address of Claim:        City:      State:

Please list details about the Claim below:

Is the Claim  Open or  Closed?

Amount Paid on Claim: $

3rd Claim

Name of Claimant:      Date of Claim:

Address of Claim:        City:      State:

Please list details about the Claim below:

Is the Claim  Open or  Closed?

Amount Paid on Claim: $

Additional Details

Please list below any additional details in the space provided below:

When you click "Submit Quote" button, your application will be emailed to one of our representatives, who will contact you shortly.

      

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