Contractor's Insurance

Business Name: 
Contact Name: 
   Birth Date:
Mailing Address: 
     State:      Zipcode: 
Phone Number: 
      Fax Number: 
E-Mail Address:

Business Type:
Year Started Business: 
Years Experience:   (if less than 3 years in business)

Required for Quote:
Annual Payroll:
# of Employees
(including yourself & partners):
Paid to Sub-Contractors:
Annual Gross Sales:

Current Policy Information:

Your current insurance company:        Policy Expires: 

Type of Contractor: 

If Janitorial, please provide the service that you provide
General Cleaning (dusting, floor cleaning, restroom cleanup)
Carpet Cleaning
Snow Removal
Chimney Cleaning
Pest Control/Extermination
Fire Restoration
Maid/Housekeeping Services
Degreasing Service (restaurant grease traps/Ansul Systems)
Industrial Cleaning
Ceiling Tile Cleaning
Elevator Maintenance
Parking Lot Maintenance
Death Scene Cleanup
Building Security
Cleaning/Renovating Outside Building Walls
Building Construction or Renovation
Landscaping (including lawn mowing
Floor Waxing and Buffing
Exterior Window Cleaning above 1st Floor
Heating/Ventilation/Air Duct Cleaning or Service
Aircraft Service and maintenance

Describe any other services that you perform, that are not listed above:

If you have any commercial customers, please indicate the nature of their businesses:

Property Coverages
Property to be Insured Insured
Building (Construction:  )
Contents (on your premises)
Misc. Tools/Equipment (no item over $ 500)
$ 250 Deductible
Scheduled or Listed Tools/Equipment (Items over $ 500)
Materials on the jobsite

Liability Coverages

Liability Limit per Occurrence: 

Insurance Losses in the Last 3 Years
What Happened?


4170 William Penn Highway, Suite 1
Murrysville, PA.  15668-1890
(724) 327-8474   Fax: (724) 327-7911
Toll Free: 1-800-977-2999   Fax: 1-888-800-0034