Contractor Quote Sheet

Quote Needed By:

Producer

Agent to Email Quote F

Insured Info

Customer Name and any DBA

Contact Name

Phone Number

FEIN

SSN

Birthdate

Alternate Phone Number

Type

Address

Address Line 1

Address Line 2

City

State

ZIP Code

Contractors License No.

Type/Description of Business

How long in Business?

If less than 3 years, how many years of experience?

GL and WC Underwriting

Officers Included or Excluded?

Included Excluded

Who are Corporate Officers?

Any subs used?

Yes No

For what?

Total paid out for Subcontractors?

Total paid out for Insured

Worker's Compensation

Total # of Employees

Short Answer

Code

Description

# of Employees

Payroll $

Code

Description

# of Employees

Payroll $

Code

Description

# of Employees

Payroll $

Code

Description

# of Employees

Payroll $

Current Experience Mod

Attach Mod worksheet from NCCI

Current Carrier

Attach Loss Runs for the last 3 years

Yes No

File

No File Chosen

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General Liability

Limit

Aggregate

GL Payroll

Gross Sales

Other GL Exposures

Contractors Equipment

Attach description and provide value

Misc. Other Coverages

Tools?

Installation Floater?

Other Info