JOSEPH E. SCHINDLER INSURANCE AGENCY

One Wall Street
Burlington, MA. 01803
Phone 781.272.7505

 

CONTRACTOR INSURANCE REQUEST

CONTACT INFORMATION
Company Name
Address
City
State   Zip Code
Phone
E-Mail
Contact Name
UNDERWRITING INFORMATION
Trade
Type of Business
Proposed effective date
How long in business
Years Trade Experience
Estimated Annual Payroll
# Of Full Time Employees
# Of Part Time Employees
Do you use subcontractors?
a. Work Subcontracted
b. % of work subcontracted		 Yes  No (If yes answer a & b)
Any claims submitted over 
the last 3 years?		 Yes   No

Description of claims including date & amount paid.

COVERAGE LIMITS
Liability Each Occurrence
Tools ( Miscellaneous ) Equipment limit
Contractors Equipment limit
Deductible option