R.R.I.S. CONTRACTORS POLLUTION LIABILITY QUOTE REQUEST                 

Please provide the following contact information:   

 (The Referral Agent is the name of your Insurance Agent in our office or how you became aware of our website)

First Name
Last Name
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Contractor License # / FEIN #
Work Phone
FAX
E-mail
URL

Please provide quotes for :

General Liability       Workers Compensation    Commercial Automobile   Commercial Property   
License Bond            Performance Bond        Course of Construction  Life                  
Group Medical           Pollution Liability 

General Liability Limit Requested (choose one):

$100,000 $300,000 $500,000 $1,000,000 occurrence/$1,000,000 aggregate $1,000,000 occurrence/$2,000,000 aggregate

Please describe your operations:

What is the name of your current insurance carrier?

What is your current expiration date? :

Please describe any claims you have had in the past 5 years with date of loss:

What are your annual gross receipts?

How much will your sub contractors cost over the next 12 months?

How many active owners are there in your business?

How many employees do you have?

What is your estimated payroll over the next 12 months?

How many years have you been in business?

How many years experience do you have?

To equal 100% total, please fill in the percentage of work you do as follows:

% Residential
% Commercial
% Industrial

To equal 100%, please fill in the percentages of the following work you do:

% New Construction
% Service and Repair
% Remodeling

Use this for addional explanation area: