General Information
Name of Business:
Inspection Contact Name:
Mailing Address:
City:	State:   Zip:
Location Address:
City:	State:   Zip:
Business Phone:	Fax:
Contact Email Address:
Business Status:	Individual Corporation Partnership Joint Venture     Years in Business:

Current Insurance Information
Company Name (not agency):	Premium: $
Effective Date:	Expiration Date:
Please List Any Other Previous Carriers Over the Past 3 Years Below:
Carrier Name:	Premium: $
Carrier Name:	Premium: $

Project/Work Information
Please write a Description of Operations below:
What percentage of your work is:  (each line must total 100%)	Commercial %   Industrial %   Residential %
	New Construction %   Remodel/Additions %
What percentage of your work is as a:	General Contractor: %   Subcontractor: %
What percentage of your work is:	Subcontracted Out: %   Sub Costs: $
Do you collect certificates of insurance at a $1,000,000 limit?:	Yes     No

Receipts / Payroll / Dollar Value Info
Gross receipts for the past 3 years:  and the next 12 months:	(3rd yr prior) $ (Last 12 mths) $ (2nd yr prior) $ (Next 12 mths) $
Number of owners/officers/partners active at the job site or supervising:
Payroll of employees excluding owners, officers, partners & clerical:	$
Dollar value of average job completed incl. all materials, labor & equipment:	$
Describe any project(s) underway or planned for the next year, including values below:

Miscellaneous and Legal Info
Have you ever performed ground up construction involving condominiums, townhouses, apartments, or single family tract developments of two (2) or more?:	Yes   No
Have you ever been named in litigation regarding faulty construction?:	Yes   No
Are there any claims or legal actions pending?:	Yes   No
Do any of the entities named in the application have knowledge of any pre-existing act, omission, event, condition or damages to any person or property that may potentially give rise to any future claim or legal action against any such entity?:	Yes   No

 

Claims History

Enter all claims or occurrences that may give rise to claims for the prior 3 years. This information is kept strictly confidential

Claim #1	Claim Status: Closed   Open
Date of Occurrence:	Date of Claim:
Type/Description of Occurrence or Claim:
Amount paid on your behalf:	$   Amount reserved on behalf: $

Claim #2	Claim Status: Closed   Open
Date of Occurrence:	Date of Claim:
Type/Description of Occurrence or Claim:
Amount paid on your behalf:	$   Amount reserved on behalf: $

 

Additional Comments

Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough space, please enter them here.

Select Office for Delivery

Please select an office below for delivery of this quote request:

Brouwer Hansen and Izdebski Insurance Associates    Toms River, New Jersey Bayshore Insurance Agency    Tuckerton, New Jersey Green Insurance Agency    Pt. Pleasant, New Jersey Chesney Stanton Insurance Agency    Paulsboro, New Jersey Stanton Insurance Agency    Cherry Hill, New Jersey Taylor Sawyers Insurance Agency    Vineland, New Jersey

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