contractors insurance underwriter

TargetContractors Survey

Your Name (required)

Your Company Name (required):

Your Phone (required):

Your Email (required):


Years in business:

Contractors License #:

Liability Expiration Date:

Workers Compensation Expiration Date:

Automobile Expiration Date:

Complete description of operations:

% residential

% commercial

% new construction

% remodel

% service/maintenance

Do you use subcontractors?

If yes, what percentage of your receipts is for subcontract labor?

Do you require subs to carry insurance with equal or greater limits than yours?

What is the total amount you pay to insured subs?

What is the total amount you pay to uninsured subs?

What type of work is subcontracted?

Total estimated gross sales last year

Total estimated gross sales estimated for next year

Current Liability Limit

Current Workers Compensation Employers Liability Limit

Current Automotive Liability Limit

Endorsements Required
AIWOSPrimary/Non?contributoryAggregate per job

Employee Class Payroll FT PT
Plumbers $ # #
Clerical $ # #
Sales $ # #
Other (describe) $ # #

Current Insurance Agent Name

Name Of Insurance Agency

Agent Telephone Number

Agent Email

Additional Information Needed

  1. Currently valued loss runs ? past 3 years
    Upload a file: .txt, .pdf .jpg filetypes accepted
  2. Experience mod worksheet, if applicable
    Upload a file: .txt, .pdf .jpg filetypes accepted
  3. For commercial auto coverage, vehicle list with coverage needed & MVRs if available
    Upload a file: .txt, .pdf .jpg filetypes accepted

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