Artisan Contractors Quote Request
**This form is not for General Contractors**

Reason for insurance request:
New in business Currently in business with no prior insurance
They are Cancelling my Account Account is going to Non-Renew Searching for a better price
Applicant Name: Individual Partnership Corporation
Type of Contractor:
Mailing Address
Location of Premises
Home Phone # Work Phone #
Fax # Email:
Is Insured Within Municipal City Limits? Yes No
Describe type of work done by applicant–include a description of the most recently completed project:
UNDEUNDERWRITING INFORMATION – (Explain all YES responses)
No. Years in Business No. Years Experience
1. Is the applicant a subsidiary of another entity or does the applicant have any subsidiaries? Yes No
2. Any exposure to flammables, explosives, chemicals? Yes No
3. Does applicant draw plans, designs, specifications? Yes No
4. Does the applicant lease equipment with/without operators? Yes No
5. Any policy or coverage declined, cancelled or non-renewed during the prior 5 years? Yes No
Explain all Yes Responses.
ELIGIBILITY REQUIREMENTS – Explain all YES responses
1. Does applicant hold a General Contractors or Builders License? Yes No
2. Does applicant ever act in the capacity of a General Contractor or Builder? Yes No
3. Does applicant ever do any exterior work on buildings over three stories in height? Yes No
4. Does applicant manufacture or sell products under his name? Yes No
5. Does applicant perform work on boats or ships or engage in boating or shipping operations? Yes No
6. Does applicant sponsor sporting or social events? Yes No
7. Will applicant’s cost of subcontracted work ever exceed 10% of gross receipts? Anticipated
cost of work you will sublet to others? %		 Yes No
8. Percent of Residential Work %   Commercial Work %  
9. Will applicant’s annual gross receipts exceed $1,000,000?Anticipated annual gross receipts?
$ 		Yes No
10. Will applicant’s annual payroll exceed $300,000?Anticipated annual payroll? $ Yes No
11. Does applicant ever do any asbestos removal? Yes No
12. Has applicant performed any work of new residential properties, town homes, condominiums
, row homes, apartments, housing project or dwellings prior to the certificate of occupancy?		 Yes No
13. Will applicant ever perform work of new residential properties, town homes, condominiums
, row homes, apartments, housing project or dwelling prior to the certificate of occupancy?		 Yes No
14. Has the applicant ever had any construction defects, products liability or other negligence
claim made against them?		 Yes No
15. Has the applicant ever been named in a lawsuit alleging construction defects? Yes No
Explain all Yes Responses.
PRIOR INSURANCE INFORMATION
New in business: With at least 3 years experience in the same work as described above.
Name of prior employer
In business without prior insurance or where there has been a gap in prior insurance of 30 days or more.
Prior carrier: Policy Number: Expiration Date: *
* Fax a copy of renewal notification or policy declaration from prior carrier expiring less than 30 days from effective date to qualify for discount.
PRIOR LOSS INFORMATION
ENTER ALL LOSSES FOR THE PRIOR 5 YEARS.     NONE
Date of loss
Type of loss
Description of loss, corrective measures (if applicable)
Amount paid
Reserve
No. Of  FULL-TIME EMPLOYEES (Include Self)
No. Of PART-TIME EMPLOYEES
Commercial General Liability Limits
$100,000/$100,000    $300,000/$300,000    $500,000/$500,000      $1,000,000/$1,000,000
($ 100,000 Limits = $1,000 MINIMUM PREMIUM)
($ 300,000 Limits = $1,000 MINIMUM PREMIUM)
($ 500,000 Limits = $1,000 MINIMUM PREMIUM)
($1,000,000 Limits = $1,500 MINIMUM PREMIUM)
Additional Comments:
IMPORTANT NOTE: This form is provided as a convenience to you. We will make a good faith effort to obtain competitive quotes for your review. Depending on the type of business, we may require more information and will contact you if necessary. Your submission of this form DOES NOT guarantee that any binding offers will be forthcoming from insurers we represent.