General Information
Contact Name:
Business Name:
Address:
City:
State:	Zip:
Phone:	Fax:
Email Address:
# of years in business:
Renewal date:
Current Carrier:

Business Information
What type of painting do you do?:
Do your operations include:
Sandblasting*:	Yes   No
Are you frequently working at heights above 15 feet?*:	Yes   No
Majority of your work interior?*:	Yes   No
*This program is designed for interior painting contractors with infrequent work at heights above two stories and no sandblasting. If this does not fit your operation, please call to discuss before continuing the application.
Total # of full time employees:
Part time employees:
Will this fluctuate?:	Yes   No
Is employee turnover high?:	Yes   No
Estimated annual receipts:	$
Approximate percentage of work performed by sub-contactors:	%
If your payroll exceeds $250,000, please list last 5 jobs:
Is proof of insurance required from sub-contractors?:	Yes   No
Do you maintain an office or place of business away from your residence?:	Yes   No
If yes, please describe (office, warehouse, etc.):

Property Coverage
Physical address, including county:
Building replacement cost (if applicable):	$
Contents Replacement cost:	$
Year Building Built:
Square Footage:	Sq. Ft.
Do you have an alarm?:	Yes   No
Computer Equipment Value
Hardware Replacement cost:	$
Software Replacement cost:	$

Commercial Automobile Coverage
Please supply the following information (Check box if you would like us to contact you for a copy of this information from your current policy)
Year, Make, and Model of all autos:
Liability limits on current policy:	$
Deductibles on current policy:	$
Cost New if full coverage desired:	$
County where each auto is kept at night:
Any owners who do not have a personal auto policy?:	Yes   No
If yes, who?:

Contractors Equipment
We will contact you for a copy of your equipment list, including values. You may choose to insure your equipment for either its replacement cost or actual cash value. Choose One:     Replacement Cost   Cash Value
Value of most expensive piece of equipment you rent:	$
Amount you pay to rent equipment each year:	$

General Liability Coverage
Aggregate Limit:	$
Products/Completed Operations Aggregate:	$
Personal and Advertising Injury:	$
Each Occurrence Limit:	$
Fire Damage Legal Liability:	$
Medical Expense:	$

Payrolls
Painting - Interior:	$
Painting - Exterior - Structures less than 3 stories:	$
Painting - Exterior - Structures exceeding 3 stories:	$
Paperhanging:	$
Drywall Installation:	$
Contractors, Executives, Supervisors or Attendants:	$
Other (Explain):	$
Cost
Adequately Insured Subcontractors:	$

Workers' Compensation Coverage
Payroll
Painting:	$
Paper Hanging:	$
Contractors, Executives, Supervisors:	$
Executive Officers - Maximum of $63,500 per officer:	$
Clerical:	$
Other (Explain):	$
Experience Modifier:	(We will contact you for a copy)
Federal ID #:

Additional Policy Information
Umbrella Policy
$1,000,000:	Yes   No
$2,000,000:	Yes   No
Other:	$
Installation Floater Policy
Maximum single job contract price:	$

Additional Comments

Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough fields above, 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.

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