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ROOFERS LIABILITY INSURANCE QUOTE REQUEST
Complete the following information if you would like to obtain an Artisan Contractor Insurance quote. Please understand this is not an application. An application will be sent to you if coverage is desired. All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.
Personal Information
What is your name?	Last
What is your name?	First
What is your business name?	Business Name
What is your address?	Street
	City
	State
	Zip
Telephone number?
Telephone number?	Business
Cell number?	Cell
Fax number?	Fax
Email address?	Email
Underwriting Information
How many active owners?	Number of Owners	Exclude Spouses
What is the payroll amount of the employees?	Actual Payroll of Employees	Exclude Owners Payroll
Number of Employees	Number of Employees	Exclude Owners
What is the total annual gross?	Total Annual Gross Receipts
What are the annual sub costs?	Total Annual Sub Costs
What is your classification?	Classification
What is your contractors license number?	Contractors License Number if required by your State
Years of experience in this business?	Years of Experience
Amount of Liability	Limits of Liability	100,000300,000 500,000 1,000,000
Do you have insurance?	Current Insurance	( Y / N )
Name of Current Carrier	Current Carrier
Years Insured	Years Insured
How many years have you operated under your current business name?	Years Operated Under Current Name
Do you do hot tar work?	Percent is Hot Tar
What is the percentage of work done on Residential?	Percentage on Residential
What is the percentage of work done on Commercial?	Percentage on Commercial
What is the percentage of work done for Remodeling/Repair or Maintenance	Percentage on Remodeling/Repair or Maintenance
What is the percentage of work done on New Homes prior to certificate of occupancy?	Percentage of New Homes prior to certificate of occupancy
Please provide a brief description or sample of the work being completed by your company.	Brief Description of work being performed