Phone: (781) 641-3300

Fax: (781) 777-1402

 

General Liability Insurance Request

Helpful Info

We would like to provide you with a free, no-obligation insurance quote. Please provide as much information as possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

Please be sure to supply your phone number and email address so that we may contact you after receiving this notification.

Current Insurance Information

Please list any other previous carriers over the page 3 years below.

Helpful Info

We would like to provide you with a free, no-obligation insurance quote. Please provide as much information as possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

Please be sure to supply your phone number and email address so that we may contact you after receiving this notification.

Project/Work Information

What percentage of your work is:
(each group must total 100%

 
 
 

What percentage of your work is as a:

 

What percentage of your work is:

 

Do you collect certificates of insurance at a $1,000,000 limit?

YesNo

Helpful Info

We would like to provide you with a free, no-obligation insurance quote. Please provide as much information as possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

Please be sure to supply your phone number and email address so that we may contact you after receiving this notification.

Receipts / Payroll / Dollar Value Info

Gross receipts for the past 3 years:
and the next 12 months:

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:

Helpful Info

We would like to provide you with a free, no-obligation insurance quote. Please provide as much information as possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

Please be sure to supply your phone number and email address so that we may contact you after receiving this notification.

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?

YesNo

Have you over been named in litigation regarding faulty construction?

YesNo

Are there any claims are legal actions pending?

YesNo

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 again any such entity?

YesNo

Helpful Info

We would like to provide you with a free, no-obligation insurance quote. Please provide as much information as possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

Please be sure to supply your phone number and email address so that we may contact you after receiving this notification.

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

OpenClosed
Claim #2

Claim Status

OpenClosed

Helpful Info

We would like to provide you with a free, no-obligation insurance quote. Please provide as much information as possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

Please be sure to supply your phone number and email address so that we may contact you after receiving this notification.

Additional Comments

Helpful Info

We would like to provide you with a free, no-obligation insurance quote. Please provide as much information as possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

Please be sure to supply your phone number and email address so that we may contact you after receiving this notification.