Saperstein Agency, Inc. -- Builder/Contractor Insurance Program Form

Saperstein Agency, Inc.


Builder/Contractor INSURANCE PROGRAM		We would like to provide you with a free, no-obligation builder/contractor 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. We will contact you when this is received to discuss your insurance needs more adequately.

General Information

Name of Business:

Inspection Contact Name:

Position:

Main Office Address:

City:

State: Zip:

Business Phone:

Fax:

Business WebSite Address:

http://

*Contact Email Address (Required):

Years in Business:

What type of coverage's are
you interested in:

Current Insurance Information
Insurance 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:

How many company owned vehicles do you insure:

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: %

What is your cost to subcontractors for:

Electrical:	$		Plumbing:	$
Masonry:	$		Other:	$

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

Yes No

Receipts / Payroll Information
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:	$
# of employees providing contracting labor (not including clerical or office personnel):	Full Time: Part Time:
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 Information
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
Do you or have you ever designed or engineered a project or job?:	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: $

Please Answer the Following Questions
to enable us to serve you better

Please indicate your concern regarding your current insurance protection:

Price
Too Much Coverage
Too Little Coverage

Insurance Company/Agency not familiar
with your business or household need

How would you rate the service that your current agent/broker provides:

Excellent

Adequate

Poor

If you could change one thing about your current insurance protection, what would it be:

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.