Florida Alliance Insurance -- Builder/Contractor General Liability Quote Form

813-661-7200
800-606-7211
www.floridainsurancequotes.us
www.floridaallianceinsurance.com

Builder/Contractor General Liability Insurance Quote
We would like to provide you with a free, no-obligation general liability insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

     This Online Application is on a Secure Server. Click on the seal on the left for more information on the certificate's authentication. Privacy Statement: Any information provided by a consumer or customer via our online forms WILL be held in the strictest confidence. No information will be shared with others. All submissions will be responded to within two business days.

General Information

Name of Business:

Inspection Contact Name:

Mailing Address:

City: State: Zip:

Location Address:

City: State: Zip:

Business Phone: Fax:

Contact Email Address:

Business Status: Years in Business:

Current Insurance Information

Company Name
(not agency): Premium: $

Effective Date: Expiration Date:

Please List Any Other Previous Carriers Over the Past 3 Years Below:

Carrier Name: Premium: $

Carrier Name: Premium: $

Project/Work Information

Please write a Description of Operations below:

Please list percentages for each category below. Each column must add up to 100%.

% of your work that is: % of your work that is: % of work you do as:

Commercial %
Industrial %
Residential %

100% New Construction %
Remodel/Additions %

100% General Contractor: %
Subcontractor: %

100%

What % of your work is Subcontracted out?: %

Please list your Subcontractor Costs: $

Do you collect certificates of insurance at a $1,000,000 limit?: Yes No

Receipts / Payroll / Dollar Value Info

Gross receipts for the past 3 years and the next 12 months: (3rd yr prior) $
(Last 12 mths) $ (2nd yr prior) $
(Next 12 mths) $

Number of owners/officers/partners active at the job site or supervising:

Payroll of employees excluding owners, officers, partners & clerical: $

Dollar value of average job completed incl. all materials, labor & equipment: $

Describe any project(s) underway or planned for the next year, including values below:

Miscellaneous and Legal Info

Have you ever performed ground up construction involving condominiums, townhouses, apartments, or single family tract developments of two (2) or more?:   Yes
  No

Have you ever been named in litigation regarding faulty construction?:   Yes
  No

Are there any claims or legal actions pending?:   Yes
  No

Do any of the entities named in the application have knowledge of any pre-existing act, omission, event, condition or damages to any person or property that may potentially give rise to any future claim or legal action against any such entity?:   Yes
  No

Claims History
Enter all claims or occurrences that may give rise to claims for the prior 3 years.
This information is kept strictly confidential

Claim #1 Claim Status: Closed Open

Date of Occurrence: Date of Claim:

Type/Description of Occurrence or Claim:

Amount paid on your behalf: $ Amount reserved on behalf: $

Claim #2 Claim Status: Closed Open

Date of Occurrence: Date of Claim:

Type/Description of Occurrence or Claim:

Amount paid on your behalf: $ Amount reserved on behalf: $

Additional Comments

Please give any additional comments you feel appropriate for this quotation. If you have
additional information where there was not enough space, please enter them here.

Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.

This General Liability Quote Form Copyright © 1999 - by ENHANCED Web Services

Copyright © Florida Alliance - All Rights Reserved