General Liability

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Company Information

Date *
Best Contact Time
Business Name *
License #
Contact First Name *
Contact Last Name
Telephone Number *
Facsimile
Email Address *
Interest Level Please enter a value between 1 and 10
Description of Operations

Percent of Overall Operations "Total Percentage should equal 100%"

Remodeling % *
Structural Remodel % *(weight bearing)
Service/Repair % *
New Construction % *
New Residential % *
New Commercial % *
Residential % *
Commercial % *
Industrial % *
HOA/Condo % *
Heating Devices Used % *

Estimated Figures

Gross Receipts *
Sub Out Costs *
Field Payroll - owner excluded *
Number of Field Employees *
Full Time Employees *
Part Time Employees *
Claims Past 3-5 years
Current Provider
Expiration Date
Current Premium
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Comments / Additional Info
Application Information THIS APPLICATION CONTAINS THE INFORMATION NEEDED TO START YOUR POLICY. IN SOME CASES IT MAY BE NECESSARY TO TRANSFER THIS INFORMATION TO ONE OR MORE CARRIER SPECIFIC FORMS. IF THAT IS NECESSARY WE WILL COMPLETE THEM FOR YOU AND SIGN ON YOUR BEHALF WITH THE INFORMATION FROM THIS APPLICATION. CLIENT AGREES TO INDEMNIFY AND HOLD HARMLESS TOP CONTRACTORS INSURANCE, ANY OF ITS EMPLOYEES AND AGENTS, ALONG WITH ANY OF ITS AFFILIATED COMPANIES FROM AND AGAINST ANY AND ALL CLAIMS ARISING OUT OF OR RELATION TO ANY ALLEGED FAILURE TO ACT ON THE PART OF THE CLIENT WHICH RESULTS IN ANY CLAIM, DEMAND, ACTION, OR CAUSE OF ACTION AGAINST TOP CONTRACTORS INSURANCE SERVICES INC, OR ITS AFFILIATED COMPANIES.

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