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On-Line Contractor
General Liability Quote Form
One Simple Form - takes only 2-3 Minutes!

Your Name:
BUSINESS Name:
Mailing Address:
City:
State: (Must be Pennsylvania)
Zip/Postal:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Phone:
Fax (optional):
 
Business Underwriting Information
Type of operation:
Describe operations in detail:
License class:
License Number:
 
Limit of Liability
Coverage Requested?
$300,000
$500,000
$1 Million
 
Currently Insured? Yes No
Name of Carrier & how long insured?
Prior Claims? Yes No
Describe claims in detail:
 
Years in business:
Years experience in field:
Percentage of work residential:
Percentage of work commercial:
 
Number of Active Owners:
Number of Employees: 0   1   2   3+
Annual Employee Payroll: $
Annual Gross Sales: $
 
Do you subcontract work? Yes No
(If yes, what percentage of your work
is subbed, and what kind of work?)
Do you do foundation work? Yes No
Do you work on condos? Yes No
Employees paid over $18/hour? Yes No
Do you have a safety program? Yes No

 
Comments/Remarks:
 
Send my quotation via: E-Mail Fax
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For Insurance Information contact one of the Qualified Staff at:
Specialty Insurance Agency     567 Kelly Blvd. (PO Box 116)     Slippery Rock, PA  16057
E-Mail Questions or Service Needs at: service@specialtyinsuranceagency.net
Phone: 800-782-6459 (Toll-free) 724-794-5081 (Local), or by Fax at: 724-794-3859
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