First Name
*
Last Name
*
Email
*
Phone
*
Do They Have CGC License?
Yes
No
What is the name of the company?
*
FEIN
Needed By
*
Needed By
ASAP
2 - 3 Days
1 Week
1 Month
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State
*
City
Address
Postal code
Scope of Work & Notes
*
% of Exterior Services
*
% of Interior Services
*
Type of Work
*
Type of Work - Multiple Quotes Survey
Commercial
Residential
Both
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% of Commercial Areas
*
% of Residential Areas
*
Max Height Exposure
*
Max Height Exposure - Multiple Quotes Survey
Ground level no more than 15 ft
Up to 2 stories
Up to 3 stories
Above 3 stories
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Percentage of work above 3 stories
Percentage of work from 2 stories to 3 stories
What equipment is used to reach heights above 15 ft? - Multiple Quotes Survey
*
What equipment is used to reach heights above 15 ft? - Multiple Quotes Survey
Ladders
Scaffolding
Cherry Picker / Bucket Truck
Other
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Percentage of work below 15ft - Multiple Quotes Survey
Percentage of work from 15ft to 2 stories - Multiple Quotes Survey
Subs Used
*
Subs Used
Yes
No
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Estimated Amount Paid to Sub Contractors Annually
*
Type of Services Subbed Out
*
What type of insurance do you want quotes for?
*
After each policy section you will be able to add additional quotes if needed
Workers Comp
General Liability
Umbrella
Commercial Auto
All
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Total Number of Employees in your Business
*
Class Code for Clerical Workers
How Many Clerical / Admin Employees do you have?
Annual Gross Payroll for all Clerical Employees Above
WC Class Code for Labor Employees
How Many Labor Employees do you have?
Annual Gross Payroll for all Labor Employees Above
Do you need to add Additional Employees?
*
Yes
No
Class Code Non Labor Employees #2
How Many Non Labor Employees Do You Have For This Category? Number #2
Annual Gross Payroll for Non Labor Employees Above #2
WC Class Code for Labor Employees #3
How Many Labor Employees Do You Have For This Category? Number #3
Annual Gross Payroll for Labor Employees Above #3
Claims In The Past Three Years?
*
Accidents or Claims Within The Past Three Years?
Yes
No
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How Many Claims Within the Last 3 Years?
Estimated Value of Claims
Do You Need Any Additional Quotes?
*
Do You Need Any Additional Quotes?
General Liability
Umbrella
Commercial Auto
No
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Anticipated Annual Gross Sales
*
Total Annual Payroll of Employees
*
How many employees do you have?
*
Number of Owners
*
Is Any Work Subcontracted Out?
*
Do you pay any sub contractor companies or people as 1099?
Yes
No
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Percentage of Work Subbed Out
*
Type of Work Subbed Out
*
Estimate how much you plan on paying to subs over the next 12 months
*
Do You Need Any Additional Quotes?
*
Do You Need Any Additional Quotes? -22
Workers Comp
Umbrella
Commercial Auto
No
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Desired Umbrella Limits
*
Do You Need Any Additional Quotes?
*
Do You Need Any Additional Quotes? - 3
Workers Comp
General Liability
Commercial Auto
No
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Desired Limits
Drive Other Car?
*
Yes if you have other cars and want this quote to insure them as well
Yes
No
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Vin Number
*
Comprehensive Deductible
Comprehensive Deductible
500
1000
1500
2500
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Collision Deductible
Collision Deductible
500
1000
1500
2500
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Radius
Garaging Address
Driver License Number
*
Driver Name #1
Birthdate #1
Civil Status #1
Civil Status - 1
Single
Married
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Do You Need To Add Another Driver?
*
Yes
No
Driver License Number #2
Driver Name #2
Birthdate #2
Civil Status #2
Civil Status - 2
Single
Married
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Do You Need To Add Another Driver?
*
Yes
No
Driver License Number #3
Driver Name #3
Birthdate #3
Civil Status #3
Civil Status - 3
Single
Married
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Do You Need Any Additional Quotes?
Do You Need Any Additional Quotes? - 4
Workers Comp
General Liability
Umbrella
No
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Any Additional Comments?
Underwriting Documents - Multiple Quotes Survey
Here you can upload any helpful documents to expedite the issuance of an underwritten and approved quote. For example, pictures of the owners Drivers License, current or previous policies, loss run reports, etc.