Contractor & Janitorial Package

Company Name:

Street Address:

Town:

State:

ZIP:

Construction Class:

Operations Description:

Please provide details for all of your business operations.

Insurance History:

If Previous Insurance Lapsed, Why?

Years in Business:

Property Coverage: (Complete if Desired)

* **(IF YOU HAVE MORE THAN ONE LOCATION, PLEASE SUBMIT 1 FORM FOR EACH LOCATION; HOWEVER YOU ONLY NEED TO FILL IN THE NAME AND PROPERTY INFORMATION FOR EACH ADDITIONAL LOCATION***

Location # :

Fire Hydrants within 1000 Feet:

 

Fire Station within 5 Miles:

Sprinklers:

 

Central Station Monitored Burglar Alarm:

 

Central Station Monitored Fire Alarm:

 

Year of Construction:

Building Construction Type:

 

Building Value if Coverage is Desired(Enter $ Amount):

Contents Value if Coverage is Desired(Enter $ Amount):

 

Deductible:

Glass Coverage:

 
  • If Yes, Linear Feet (Enter #):

Sign Value (Enter $ Amount):

 

Liability Coverage:

Gross Annual Employee Payroll (Enter $ Amount):

 
Gross Annual Owner(s) Payroll (Enter $ Amount - If Any)

Number of FT Employees Doing Work:

Number of Owners Doing Work:
Number of PT Employees Doing Work:
Number of Owners/Strictly Clerical:
Number of FT Employees/Strictly Clerical:
Number of PT Employees/Strictly Clerical:

Additional Insured(s):

 
  • Number Requested:

 

General Liability Limit:

 

Umbrella Liability (If Desired):

Underwriting:
 
Percentage of Subcontracted Work:
Area of Operations: New Jersey      % of Work Done in State
Delaware      % of Work Done in State
Maryland      % of Work Done in State
New York      % of Work Done in State
Any Roofing?
  • If Yes Explain:
Any Asbestos Removal?
  • If Yes Explain:
 
Any LPG Work?
  • If Yes Explain:
Any Earth Movement or Excavation?
 
Any Demolition?
  • If Yes Explain:
Does 25% or more of your revenues come from window washing, floor stripping &/or waxing services?
 

Claims Information:

Any Property Claims within 3 Years:

 
  • If So, Describe (Include Date and Pay Out Amount):

 

Any Liability Claims within 3 Years:

 
  • If So, Describe (Include Date and Pay Out Amount):

 

Contact's Name:

 

Contact's Phone Number (Include Area Code):

 

Contact's Fax Number (Include Area Code):

 

Contact's E-Mail Address: