Contractors Liability Insurance Quote Form

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Beach Cities Insurance Services

Contact person:Bryan McDonald
1105 N. Coast Highway
Laguna Beach, CA 92651
Toll Free: 800-205-8400
P.: 949-494-0421
F.: 949-494-0956

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Contractors Liability Insurance Quote Form

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Your Name: *

Business Name:

Contractor's License Number:

Your License Type:

Physical Location Address:

Address (cont):

City:

State:

Zip/Postal code:

Mailing Address:

Address (cont):

City:

State:

Zip/Postal code:

Work Phone:

Mobile Phone:

Fax:

E-mail: *

What % of your work is:
% Residential, % Commercial, % Industrial, % New Construction, % Structural Remodeling/Additions, % Non-structural Remodeling, % Interior, % Exterior

Estimated Annual Gross Receipts for the Next 12 Months:

Estimated Annual Employee Payroll:
(do not include owner's salary, officers,sales people, supervisors, or clerical; only enter field employees)

Number of
owners, officers, and partners physically working at job sites:

Do you use subcontractors?

If so, please specify the estimated annual % of work subcontracted:

Estimated annual sub-out cost (including labor & materials): $

Subcontractors:
List the trade of each subcontractor you use and give the % of your work they perform:

Liability Limit:

Do you have insurance currently?

Current Insurance:
If so, what carrier?

When does your current policy expire?

Any claim in the last 3 years?

Recent Activity:
If yes, please explain:

Number of Years Licensed:

Number of Years Experience:

Brief Description of Your Work:

You need this coverage by...

Do You Work on New Tracts?:
(Remodel work on Tracts is not considered new Work)

Do You Work on NEW Condos, Townhouses or Apartments?
(Remodel work on condos, Townhouses and Apartments is not considered new Work)

Please describe your largest planned project in the next year.

Please describe your largest completed project in the last 3 years

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Contractors Liability Insurance Quote Form

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