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What state are you in?

What kind of work do you do?

How many employees do you have in each section?

Work-Site Employees? (Construction Etc.)

Clerical Employees? (Never leave the office.)

How many employees do you have in each section?

What is the average weekly payroll for each section?

Do you have a website?

Yes

Who are we sending the approved quote to?

Owner's name

Full business name

Contact number

Tell us about your company so we can classify you correctly

Date business was established?

How many years of experience do you have in this line of business?

Full description of operations here.

Are you a corporation, LLC, sole proprietor?

Federal ID # ( If known )

What address do we use to approve your policy?

Business mailing address.

Physical address: (If physical & mailing address are the same, please check the checkbox):

Yes

Business mailing address.

How did you hear about our agency?

#	Yes	No
Does applicant own, operate or lease any aircraft/watercraft?	Yes	No
Any current operations which involve exposure to chemicals, lead-based paint, or hazardous materials?	Yes	No
Any work performed under, on, or above water?	Yes	No
Any work which may be subject to the Jones Act, USL&H, or FELA?	Yes	No
Any work performed underground or 20 feet above ground level? (If Yes, detail max height and max depth)	Yes	No
Do any operations include excavation, tunneling, road boring, earthmoving, or other underground work?	Yes	No
Any fatalities in the past five years?	Yes	No
Is the applicant involved in any business other than that specified in the description of operations?	Yes	No
Do employees travel out of state or out of the country? If so, the scope of travel?	Yes	No
Are any group travel or ride-sharing programs provided?	Yes	No
Does the radius of operations vehicles exceed 200 miles?	Yes	No
Is there any framing, roofing, or structural operations? If yes, please explain.	Yes	No
Is a written safety program in place? <br> If "yes", what is the schedule of safety meetings?	Yes	No
Has OSHA inspected the applicant in the past three years?	Yes	No
Was the applicant cited for any violations? (If Yes, explain.)	Yes	No
Was the applicant fined? If so, how much?	Yes	No
Are any subcontractors used? (If Yes, what percentage of work is subcontracted? Also, what type of work?)	Yes	No
If any tree trimming work performed, are any climbers or bucket trucks used?	Yes	No
If any roofing work is performed, is any hot tar or hot mops used? (If Yes, what is the percent of all work completed?)	Yes	No
Please provide the percentages of commercial and residential work.	Yes	No
Any prior coverage declined, canceled, or non-renewed in the past three (3) years? (If Yes, please provide details.)	Yes	No

Let's get started on an Instant Approval, you're next!

Who are we sending the approved quote to?

Tell us about your company so we can classify you correctly

What address do we use to approve your policy?

Let's get started on an Instant Approval,
you're next!