| Are you the policyowner?
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| If no, what is your relationship to the policyowner? If yes, type "NA"
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| Note: All questions hereafter pertain to the policyowner. |
| CONTACT INFORMATION |
| First Name
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| Last Name
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| Business Legal Name
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| Contact Primary Phone Number
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| Contact Email Address
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| Mailing Address
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| City
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| State
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| ZIP / Postal Code
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| What type of Insurance do you want us to quote?
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| Describe your Contractor Operation
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| Business Type
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| Number of Owners
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| Business Street Address
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| Primary Phone Number
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| E-Mail Address
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| Number of Years in this Business?
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| Gross Annual Sales
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| Number of Employees
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| Annual Employee Payroll, or type "No Employees"
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| Are Subcontractors Used?
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| If Subcontractors are used, do you veritify that they have insurance?
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| Annual Cost of Subcontractors, or type "No Subcontractors"
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| Do you have Equipment to insure?
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| If YES, Please provide a brief description of equipment with a TOTAL VALUE to be insured. If no equipment, type "No equipment to be insured."
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| Do you current have General Liability Insurance?
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| If yes, please provide name of current Insurance carrier. If no insurance, type "NA."
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| Have you had a lapse in coverage during the past 3 years?
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| Has your company had any claims in the past 3 years?
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| Number of Additional Insureds Needed
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| Any Special Requirements
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| If yes, please explain special requirements. If no, type "NA"
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| How did you hear about us? Please let us know
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| Is there anything else that you would like for us to know concerning your quote request?
Optional
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| SIGNATURE REQUIRED |
| I have provided all of the above information for insurance purposes and I state all information is true to the best of my knowledge. I also understand that I am to discuss with the agent at D. Ward Insurance my desired limits and coverage. |
| By typing my name warrants my signature.
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| ADDITIONAL INFORMATION NEEDED |
| Please note - if the Business is insured, a copy of the policy and claim history will be required. They can be obtained from your current agent by requesting the documents to be sent electronically to you. |
| After you have sumitted your quote request, we will start working on your quote and we will help assist with obtaining your claim history. The insurance carriers require us to show prior proof of coverage along with claim history. |
| In reviewing your policy and claim history, we will let you know if we believe we can better your coverage and save money, or we will let you know your policy is competitively priced. |
| Thank you for time and we will be in touch with you today unless this is after hours or on the weekend - Debbie Ward and Valerie Moore |
| ENTER VALIDATION CODE |
| For Security of your personal information, enter code and press submit |
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