1. Choose Primary Industry:
--Select One---
Carpentry
Concrete
Drywall
Electrical
Energy
Fencing
Flooring
Framing
Garage/Sheds
Grading/Excavating
Handyman
Home Decor
HVAC
Insulation
Janitorial
Landscaping
Masonry
Outbuildings/Decks
Painting
Plumbing
Remodeling
Renovation
Roofing
Septic Systems
Spa, Pools/Water Features
Stucco/Stonework
Surveying
Tile
Wells/Water Systems
2. Number of Years in Your Industry:
--Select One---
0-1
2-5
6+
3. Primary State or Province of Operation:
--Select One---
Alabama
Alberta
Arizona
Arkansas
British Columbia
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Manitoba
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Brunswick
New Hampshire
New Jersey
New Mexico
New York
Newfoundland and Labrador
North Carolina
North Dakota
Nova Scotia
Ohio
Oklahoma
Ontario
Oregon
Pennsylvania
Prince Edward Island
Quebec
Rhode Island
Saskatchewan
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
4. Gross Annual Business Revenue:
--Select One---
less than 100k
101-250k
251-500k
over 501k
5. Gross Annual Income (Owner Only):
--Select One---
less than 50k
51-75k
76-100k
101-150k
over 150k
6. Gross Annual Payroll (Including Owner, All Employees and Subs):
--Select One---
less than 50k
51-150k
151-300k
over 301k
7. Have you had a prior CGL policy for your business?
--Select One---
No
Yes
8. Have you had CGL claim in the last 5 years?
--Select One---
No
Yes
9. During the past 5 years, has any insurer cancelled, declined or refused to issue similar insurance to the Applicant?
--Select One---
No
Yes
10. Deductible:
--Select One---
$500
$1,000
$2,500
$5,000
11. Maximum Benefit/Incident:
--Select One---
$100,000
$250,000
$500,000
$1,000,000
$2,000,000
12. Maximum Benefit/Aggregate (per Policy Year):
--Select One---
$250,000
$500,000
$1,000,000
$2,000,000
$3,000,000
13. Number of Additional Certificate Holders:
--Select One---
-None-
1
2
3
4
5
6
7
8
9
10