Business Name*
Email*
Annual Revenue* Yrs of Experience*
Select a Zip Code* Primary Operation*
# of Owners that are office/clerical ONLY:
# of Owners that are Supervisors only:
# of Owners that oversee OR perform labor:
Total # of Owners
Do you have W2 employees, 1099 labor, OR subcontractors?
Subcontractors (With insurance)
Annual cost of residential subs        
Annual cost of commercial subs        
Employees AND Uninsured 1099 labor
Choose up to 3 Job Descriptions Full Time Part Time Labor Cost WC %
GL WC
How many claims have you had in the last 3 years?
How many years have you had prior coverage?
How many new structures will you build this year?
How many roofs will be installed by your employees?
How many roofs will be installed by subs with insurance?
How many other jobs will be over 15' above the ground?
General Liability
Workers Comp
Premium Down Pymt
Premium Down Pymt
0 None
7 Submit Submit
8 Submit Submit
Select GL:
Select WC:
Limits
Employer's Liab Limits
GL ea Occur 1,000,000
Ea Injury
Pers & Adv Injury 1,000,000
Ea Person
Fire Damage
Ea Disease
GL Aggregate 2,000,000
P/CO Aggregate 2,000,000
Med Expense 5,000
HNO Auto
Total:
Down Pymt:
Entity Type 
EIN:
Contact Name
Address
City
Zip
Contact Phone# Describe your business:
PREMIUM PROPOSAL SUMMARY
General Liability Workers Comp
Addl Insured            
Premium Subtotal        
State Taxes   $0 Higher Limits    
Fees          
Total Premium:
Down Pymt:
I have provided complete owner, employee, and subcontractor information and answered all questions accurately.  I understand that once signatures are received and the down payment is made, policy fees are non-refundable and minimum earned premiums will apply. Coverage is not bound until confirmed by a licensed agent. 
Requested Effective Date
Type Name of Authorized Signer
Title
Notes
Agent Reference Only
O2
O3
C1
C2
C3
Agent Notes