14887 Hwy 105 W, Suite 102
Montgomery, TX 77356

1-866-TEXAS-45
(1-866-839-2745)

Our Texas Insurance Policies & Coverages

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Builder Contractor General Liability Insurance

General Information
Name of Business:
Inspection Contact Name:
Mailing Address:
City:State: Zip:
Location Address:
City: State: Zip:
Business Phone: Fax:
Contact Email Address:
Business Status: Years in Business:

Current Insurance Information
Company Name
(not agency): 		Premium:$
Effective Date: Expiration Date:
Please List Any Other Previous Carriers Over the Past 3 Years Below:
Carrier Name: Premium:$
Carrier Name: Premium:$
Project/Work Information
Please write a Description of Operations below:
What percentage of your work is:
(each line must total 100%)
Commercial
%
Industrial
%
Residential
%
New Construction
%
Remodel/Additions
%
What percentage of your work is as a:
General Contractor:
%
Subcontractor:
%
What percentage of your work is:
Subcontracted Out:
%
Sub Costs:
$
What limits of liability are you wanting?
Do you collect certificates of insurance at the same limits of liability? Yes No

Receipts / Payroll / Dollar Value Info
Gross receipts for the past 3 years:
And the next 12 months:
(3rdyrprior)
$
(2ndyrprior)
$
(Last12mths)
$
(Next12mths)
$
Number of owners/officers/partners active at the job site or supervising:
Payroll of employees excluding owners, officers, partners & clerical: $
Dollar value of average job completed include all materials, labor & equipment: $
Describe any project(s) underway or planned for the next year, including values below:

Builder / Contractor General Liability Insurance Quote

Miscellaneous and Legal Information
Have you ever performed ground up construction involving condominiums, townhouses, apartments, or single family tract developments of two (2) or more? YesNo
Have you ever been named in litigation regarding faulty construction? YesNo
Are there any claims or legal actions pending? YesNo
Do any of the entities named in the application have knowledge of any pre-existing act, omission, event, condition or damages to any person or property that may potentially give rise to any future claim or legal action against any such entity? YesNo

Claims History- Enter all claims or occurrences that may give rise to claims for the prior 3 years.

This information is kept strictly confidential.
Claim #1 Claim Status: Closed Open
Date of Occurrence: Date of Claim:
Type/Description of Occurrence or Claim:
Amount paid on your behalf: $Amount reserved on behalf: $
Claim #2 Claim Status: Closed Open
Date of Occurrence: Date of Claim:
Type/Description of Occurrence or Claim:
Amount paid on your behalf: $ Amount reserved on behalf: $

Additional Comments
Please provide any additional comments you feel appropriate for this quotation.
If you have additional information where there was not enough space, please enter it here.

Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.