homeservice & claimspaymentscontactsite map
  
Home
About Us
Get A Quote
Personal Insurance
Business Insurance
Other Products
Service & Claims
Insurance Resources
Contact Us
Manage My Policy 
 Builder Contractor GL Quote 
Builder/Contractor General Liability Insurance Quote

Contact Information
Name of Business:
Inspection Contact Name:
Address:
City:
 State: Zip:
Location Address:
City:
 State: Zip:
Business Phone:
 Fax Number:
Contact Email Address:
Business Status:
 Years in Business:
Current Insurance Information
Current Insurance Carrier: Premium:$
Effective Date: Expiration Date:
Please List Any Other Previous Carriers Over the Past 3 Years Below:
Carrier Name: Premium:$
Carrier Name: Premium:$
Project/Work Information
Please write a Description of Operations below:
What % of your work is:
(each line must total 100%)
Commercial % % Industrial % Residential %
New Construction % Remodel/Additions %
Whatpercentage of your work is as a:
 General Contractor: % Subcontractor: %
What percentage of your work is
 Subcontracted Out: % Sub Costs:$
Do you collect certificates of insurance at a $1,000,000 limit?
 Yes No
Receipts / Payroll / Dollar Value Info
Gross receipts for the past 3 years:
and the next 12 months:
 (3rdyrprior)$
(2ndyrprior)$
(Last12months)$
(Next12months)$
Number of owners/officers/partners active
at the job site or supervising:
Payroll of employees excluding owners,
officers, partners & clerical:
 $
Dollar value of average job completed
includingallmaterials,labor&equipment:
 $
Describe any project(s) underway or planned for the next year, including values below:
Miscellaneous and Legal Info
Have you ever performed ground up construction involving condominiums, townhouses, apartments, or single family tract developments of two (2) or more?:
 Yes No
Have you ever been named in litigation regarding faulty construction?:
 Yes No
Are there any claims or legal actions pending?:
 Yes No
Do any of the entities named in the application have knowledge of any pre-existing act, omission, event, condition or damages to any person or property that may potentially give rise to any future claim or legal action against any such entity?:
 Yes No
Claims History
Claim #1 Claim Status: Closed Open
Date of occurrence:
Date of claim:
Type description of occurrence or claim:
Amount paid on your behalf: $
Amount reserved: $
Claim #2 Claim Status: Closed Open
Date of occurrence:
Date of claim:
Type description of occurrence or claim:
Amount paid on your behalf: $
Amount reserved: $
Additional Comments
Please give any additional comments or questions

No coverage of any kind is bound or implied by submitting information via this online form

  • Information from you and other sources, such as your driving, claims and insurance histories, may be used to calculate an accurate price for your insurance.
  • We will not distribute information to other parties other than for insurance underwriting purposes.
  • By submitting this form, you agree to release us from any liability should this information be accidentally viewed by others.

Enter the security code you see above. Code is NOT case sensitive. *


© M.A. Hays Co., 2011   webmail login
Unauthorized duplication or publication of any materials from this site is expressly prohibited.


Unauthorized duplication or publication of any materials from this site is expressly prohibited.
Powered By: Insurance Web Designs Websites For Insurance Agents