Contractors Form
Please fill out this form to be contacted with a quote. You'll notice that most are not required, but the more you answer, the easier it will be for us to quote. We try to ask as few questions as necessary. Thanks!
Contractor Business Name:
Your answer
How did you hear about us?
Phone number:
Your answer
Entity type:
If not corporation: Owners full name, home address & DOB:
Your answer
FEIN Number if you have one or Social Security # if not
Your answer
Owners Date of birth:
MM
/
DD
/
YYYY
Contact name:
Your answer
Email:
Your answer
Percent Commercial work
Percent residential work
# of New Homes/year
Your answer
General Contractor?
What percent (revenue/income) of the following do you do…. (Please try and add to 100%)
0%
less than 20%
20%
40%
60%
80%
100%
Pool/Spa
Landscaping
Electrical
Snowplowing
Interior Carpentry
Drywall
Exterior Painting
Concrete-flat
Concrete-wall
Excavating
Interior Painting
Plumbing
Heating/Cooling
Exterior Carpentry
Roofing
Windows
Siding
Insulation
Year business started:
Please enter number
Your answer
# of Years experience in this field:
Please enter number
Your answer
# years with current carrier:
Please enter a number
Your answer
Any lapse in coverage or claims in the last 5 years for any of your policies? If yes, please describe.
Please respond with Yes and a description or just with No
Your answer
Gross Annual Income:
Please enter number
Your answer
# of Emp (full & part time):
Your answer
Annual Payroll (W2+1099):
Your answer
Any Subcontractors used:
Annual Subcontractor Cost:
Your answer
Do you require certificates of insurance from subcontractors w/equal liability limits:
Business Personal Property and tools coverage amount:
Please enter $ amount
Your answer
Scheduled Items and Approximate Values:
Your answer
Occupancy:
Sq Footage Occupied:
Your answer
% office space
% warehouse/shop space
% That has Sprinkler
Alarm
# of Stories total
Any Additional comments:
Your answer
Only answer Questions below if you are the building owner
Questions only necessary if you are the building owner
Building Coverage Limit (if owner):
Please only answer if you are the owner
Your answer
Building construction type:
Please tell us the Years your wiring, roofing, plumbing and heating were last updated
Your answer
Year Building Built:
Your answer
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This form was created inside of Shield Insurance Agency.