Premier Services - The Insurance Experts

Contractors Liability Insurance Application
(Quotes will be provided for Pennsylvania only)

Contact name:

Company:

Address:

City, State, Zip Code:

Phone:

Fax:

E-Mail:

Company Information

Is this company a:

If partnership or corporation, please supply list of names:

Number of years in business:

Annual payroll of employees (do not include payrolls of partners or owners):

Annual sales:

Have you carried insurance in the past? Yes No

How much liability coverage to you want?

What percentage of your operation is residential?

What percentage of your operation is commercial?

How many workers do you employ full time?

How many workers do you employ part time?

What percentage of your work is new construction?

What percentage of your work is repair or remodeling?

What state licenses do you hold?

Are you or your employees affiliated with a union? Yes No

Are subcontractors used? Yes No

If yes, what percentage is subcontracted?

Are certificates of insurance obtained to verify General Liability limits are at least as high as yours? Yes No

Do subcontractors supply you copies of endorsements to their General Liability policies showing you have been added as an additional insured? Yes No

Do you use a hold harmless agreement with subcontractors? Yes No

Do you or your employees perform any work which involves:

Asbestos Yes No

Backhoes, trenches or underground operations Yes No

Explosives Yes No

Hazardous waste Yes No

Heavy equipment Yes No

Heights above 2 stories Yes No

Hot tar Yes No

Jack hammers Yes No

Ladders or scaffolding Yes No

Lead paint Yes No

Rent or least contractors equipment Yes No

Store/transport gas/oil/propane Yes No

Toxic chemicals Yes No

Explain any "yes" answers in the text box:

Please describe your last five contracted jobs or projects:

Please explain any claims against you in the past five years. Please include date, amount of claim, and details:

Current insurance carrier:

Effective date:

Premium paid:

Do you have quotations from other companies? Yes No

Would you like a quote from us for the same coverage for easy comparison? Yes No

Who is the insurance company?

What coverage was quoted?

What was the price quoted?

How did you hear about us?

Additional Comments: