1. Business Name:    

What type of entity is your company?    ---Sole ProprietorCorporationGeneral PartnershipLimited PartnershipLimited Liability CompanyOther

2. Description of the business:    ---Agriculture: forestry and fisheries --Agricultural production- crops --Agricultural production- livestock --Agricultural services --Forestry --Fishing: hunting and trappingMineral Industries --Metal mining --Coal mining --Oil and gas extraction --Nonmetallic minerals (except fuels)Construction Industries --General building contractors --Heavy construction contractors --Special trade contractorsManufacturing --Food and kindred products --Tobacco manufacturers --Textile mill products --Apparel and other textile products --Lumber and wood products --Furniture and fixtures --Paper and allied products --Printing and publishing --Chemicals and allied products --Petroleum and coal products --Rubber and miscellaneous plastics products --Leather and leather products --Stone: clay, glass and concrete products --Primary metal industries --Fabricated metal products --Industrial machinery and equipment --Electrical and electronic equipment --Transportation equipment --Instruments and related products --Miscellaneous manufacturing industriesTransportation: Communication and Utilities --Railroad transportation --Local and inter-urban passenger transit --Motor freight transportation and warehousing --U.S. Postal Service --Water transportation --Transportation by air --Pipelines (except natural gas) --Transportation services --Communications --Electric: gas and sanitary servicesWholesale Trade --Wholesale trade- durable goods --Wholesale trade- nondurable goodsRetail Trade --Building materials: hardware, garden supply and mobile --General merchandise stores --Food stores --Automotive dealers and gasoline service stations --Apparel and accessory stores --Furniture: home furnishings and equipment stores --Restaurants: bars and dining facilities --Miscellaneous retail Finance: Insurance and Real Estate --Depository institutions --Non-depository credit institutions --Security commodity brokers and services --Insurance carriers --Insurance agents brokers and service --Real estate --Holding and other investment offices Service Industries --Hotels rooming houses camps and other lodging --Personal services --Business services --Automotive repair services and parking --Miscellaneous repair services --Motion pictures --Amusement parks and recreational services --Health services --Legal services --Educational services --Social services --Museums art galleries botanical gardens and zoos --Membership organizations --Engineering and management services --Miscellaneous servicesPublic Administration --Executive legislative and general government --Justice public order and safety --Finance taxation and monetary policy --Human resource administration --Environmental quality and housing --Economic program administration --National security and international affairs

How many years in business?    

3. Business address:    

City:    

State:       ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasU.S. Virgin IslandsUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip Code:        

4. Please indicate the state in which your business is located: ---New JerseyNew York

5. Do you currently have insurance? Yes No

6. If yes, please provide the company name here:    

7. How many years have you had coverage with this company?    

8. How many years have you had continuous coverage (With no lapse)?    

9. In the past five years have you reported any losses?      Yes No

10. If you have, were those claims:    ---Under 1000025000-5000075000-100000Over 100000

11. Describe all operations in details:

  %Painting

  %Carpentry 

  %Drywall 

  %Electrical 

   %Plumbing

   %Masonry

  % %Door, Window, Partition Install/Repair     

  %Cabinet Making/Install

  %Woodworking

%    Other

12. Commercial Work, in offices       %

    Any other Commercial Work       %

    Residential Work       %

13. Inside Buildings       %

    Vs. Outside Buildings        %

14. Is More than 5% of work is performed outside of " Home " State?      Yes No

15. Any other business owned by applicant, including any unrelated operations?

 Yes No      IF Yes, please List     

16. Any work involving:

Sewers & Drains  Yes No

Heating / Air-conditioning  Yes No

Exterior Work above 3 stories  Yes No

Tree Pruning / Spraying  Yes No

Medical or life Support  Yes No

Snow / Ice Removal  Yes No

Alarms  Yes No

Lawn Sprinklers  Yes No

Fire Sprinklers  Yes No

Backhoes Yes No

Cranes Yes No

Roofing Yes No

Below Grade Work Yes No    If yes, Maximum Depth:    

17. Liability Amount:    ---300,000500,0001,000,0002,000,000Other

     Deductible:    ---250500100025005000Other

18. Property: $  

     Business Contents:    

19. Please indicate your total # of full-time employees:    

     Total Salary? $     

20. Please indicate your total # of Part Time Employees:     

     Total Salary? $     

21. Please indicate the payroll of the owners: Total Salary?   $     

22. Please indicate your total annual payroll without owners:   $     

23. Please indicate your total Gross receipts:   $  & nbsp;  

24. Please indicate your total Cost of Subcontractors:   $     

The answer to these basic questions will help us process your information.

1) Best Time To Contact:    ---AnytimeMorning at HomeMorning ati WorkAfternoon at HomeAfternoon at WorkEvening at HomeEvening at WorkWeekends

2) Additional Comments:
Please provide any additional information you feel is pertinent to the insurance coverage you need.

1. First Name:     

2. Last Name:      

3. Phone:              

4. Email:               

5. Address:          

6. Address:          

7. City:                   

8. State:                ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasU.S. Virgin IslandsUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

9. Zip Code: