Contractor Insurance Quote | Advantixx Insurance Group

Applicant Information

Business Legal Name*

DBA / Trade Name (if applicable)

FEIN / Tax ID*

Entity Type*

Business Address*

City*

State*

ZIP Code*

Business Phone*

Contact Email*

Contact Person / Owner Name*

Title / Position

Year Business Established*

Years Under Current Ownership*

Contractor License Number*

License State*

Website URL

Trade & Operations

Primary trade / contractor type*

Describe in detail the work you perform*

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Annual Gross Revenue ($)*

Annual Payroll ($)*

Full-Time Employees*

Part-Time Employees

Seasonal Employees

Do you perform residential work?*

YesNo

Estimated % of revenue from residential work

Do you perform commercial work?*

YesNo

Estimated % of revenue from commercial work

Do you perform industrial / manufacturing facility work?*

YesNo

Do you perform government / public works projects?*

YesNo

Do you work on projects over 3 stories in height?*

YesNo

Do you perform any underground work (tunneling, excavation)?*

YesNo

Do you perform any work involving explosives or blasting?*

YesNo

Do you perform any work on bridges, dams, or waterways?*

YesNo

Do you use subcontractors?*

YesNo

Estimated % of work subcontracted out

Do subcontractors carry their own GL and WC insurance?*

Yes — AlwaysYes — SometimesNo

Do you require certificates of insurance from all subcontractors?*

YesNo

Do you perform any work outside your home state?*

YesNo

If yes, list the states where you perform work

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Largest single project value in the past 3 years ($)*

Average project value ($)*

Equipment & Vehicles

Estimated value of tools & small equipment ($)*

Estimated value of heavy equipment / machinery ($)

Do you own or operate vehicles for business use?*

YesNo

Number of owned vehicles

Number of hired/non-owned vehicles

Do you use cranes, excavators, or heavy lifting equipment?*

YesNo

Do you use aerial lifts or scaffolding?*

YesNo

Safety & Risk Management

Claims History (Past 5 Years)

Have you had any losses or claims in the past 5 years?*

YesNo

If yes, describe each claim (date, type, amount, status)

0/500

Have you ever been cancelled or non-renewed by an insurer?*

YesNo

If yes, explain

0/500

Current Insurance

Current insurance carrier

Current policy expiration date

Current annual premium ($)

Desired effective date for new policy*

Coverage Requested — Select All That Apply

Additional Information

Any additional information you would like us to know

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