Specialty Contractors Insurance Services, Inc.

General Liability

Company Name *

Date *

Name of principle *

Address *

City, State, ZIP *

Phone *

Fax

Email *

How did you hear about us?

Buisness Type	Corporation Partnership Sole Proprietor

Contractor's State License # *

Years Experience

Are you insured now?	Yes No

Is yes, with whom?

Expiration date

Current Limit of Liability

Description of Operations

What is the annual gross sales for your business?

Number of exployees?

Part Time

Full Time

What percentage of works is?

New Construction

Remodeling or Additions

How does it divide into?

Commercial

Residential

Do you use Sub Contractors?

How much of your gross sales is spent on Sub Contracting?

Describe the trades Sub-contracted

Is there any other coverage you are interested in?	General Liability Commercial Auto Property Insurance Bonds Workers Comp None

How soon do you need your insurance to start?	Immediately 1 Week 1 Month Other

If other, please state

Miles radius		(one way)

Limits Requested