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Your Name:
Mailing Address:
State: (Must be New York)
E-Mail again for accuracy:
Fax (optional):
Business Underwriting Information
Type of operation:
Describe operations in detail:
License class:
License Number:
Select Coverage Type: Contractor Liability/Package
Builder's Risk
If Builder's Risk, What is Building Value?
Limit of Liability
Coverage Requested?
$1 Million
Currently Insured? Yes No
Name of Carrier & how long insured?
Prior Claims? Yes No
Describe claims in detail:
Years in business:
Years experience in field:
Percentage of work residential:
Percentage of work commercial:
Number of Active Owners:
Number of Employees (full & part time):
Annual Employee Payroll: $
Annual Gross Sales: $
Do you subcontract work? Yes No
(If yes, what percentage of your work
is subbed, and what kind of work?)
Do you do foundation work? Yes No
Do you work on condos? Yes No
Employees paid over $18/hour? Yes No
Do you have a safety program? Yes No

Other Coverages You Would Like Information On: Tool & Equipment Floater Commercial Vehicle
Bonds, License/Performance
Workers Compensation
Builders Risk Insurance
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