Please Print this page and then provide the following information if you would like to obtain an Insurance quote. Please understand this is not an application. An application will be sent to you if coverage is desired. All information provided on is confidential and will be used solely for the purpose of developing a quote for you. email to: jerry@waterstates.com |
| Personal Information |
| What is your name? | Last | |
First | |
Middle | |
| What is your business name? | Business Name | |
| What is your address? | Street | |
City | |
State | |
Zip | |
| What is your telephone number? | Home | |
Business | |
| What is your fax number? | Fax | |
| What is your email address? | Email | |
| Underwriting Information |
| How many owners? | Number of Owners | |
| How many employees? | Number of Employees | |
| What is the payroll amount of the owners? | Payroll of Owners | |
| What is the payroll amount of the employees? | Payroll of Employees | |
| What is the total annual gross? | Total Annual Gross Receipts | |
| What are the annual sub costs? | Total Annual Sub Costs | |
| What is your classification? | Classification
|
| What is your contractors license number? | Contractors License Number | |
| What is the license type? | License Type | |
| Years of experience in this business? | Years of Experience | |
| How many years have you operated under your current business name? | Years Operated Under Current Name | |
| Have you used any other business names during the past 5 years? | Other Business Names | Yes No |
| Have you been involved in the original construction or remodeling of town homes, condos, row homes or developments of 15 or more unattached single family dwellings during the past 5 years? | Construction or Remodeling | Yes No |
| Do you construct footings or foundations which may support dwellings or other structures? | Construct Foundations | Yes No |
| Do you construct slab or monolithic floors? | Construct Floors | Yes No |
| Do you construct piers or underpinning which may support dwellings or other structures? | Construct Piers | Yes No |
| Do you construct retaining walls which may support dwellings or other structures? | Retaining Walls | |
| Do you construct fireplaces or chimneys? | Fireplaces or Chimneys | |
| What is the percentage of work done as a General Contractor? | Percentage as General Contractor | |
| What is the percentage of work done as a Sub-Contractor? | Percentage as Sub-Contractor | |
| What is the percentage of work done on Residential? | Percentage on Residential | |
| What is the percentage of work done on Commercial? | Percentage on Commercial | |
| What is the percentage of work done for Remodeling? | Percentage on Remodeling | |
| What is the percentage of work done for Renovation? | Percentage for Renovation | |
| What is the percentage of work done for Repair or Maintenance? | Percentage for Repair or Maintenance | |
| Claims Information |
| Where there any losses or claims in the last 5 years? | Losses - Claims | Yes No |
| If yes, what is the date, amount paid and description of each loss or claim? | |