Disclaimer

I understand that this does not constitute an actual "live" online quote, but is rather a submission of information to Head Insurance Group so that they may put together an insurance proposal (quote) for the above titled risk. There is no obligation on my part to purchase this insurance, and I understand that this online submission does not constitute a statement or contract for insurance.  I have read and agree with the above disclaimer.   (Box must be checked before request can be sent)

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:	Individual Corporation Partnership Joint Venture     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:
What percentage of your work is: (each line must total 100%)	Commercial %  Industrial %  Residential %
	New Construction %   Remodel/Additions %
What percentage of your work is as a:	General Contractor: %   Subcontractor: %
What percentage of your work is:	Subcontracted Out: %   Sub 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) $     (2nd yr prior) $ (Last 12 mths) $    (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.

Before Submitting Your Information...

I understand that all of the above information MUST BE COMPLETED in order to obtain an Insurance Quote. Head Insurance Group will be unable to provide me an insurance quote if any fields above are left blank or are partially filled in. PLEASE re-check your information before submitting!  I have read and agree with the above disclaimer.   (Box must be checked before request can be sent)

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.