Artisan Contractor Quote | Business Insurance Los Angeles

First Name *

Last Name *

Applicant DBA

Business Address *

Business Name *

Check if mailing address is different from above

Mailing Address *

Phone Number*

Email Address *

Proposed Effective Date: *

Type of Contractor License:*

Projected Gross Receipts	Annual Gross Receipts (past 3 years)
Next 12 months*	*	*	*

Number of owners/partners: *

# Full time employees: *

# Part time employees: *

Total Employee Payroll (no owner, clerical or sales): *

Sub-Contracting Costs: *

Business Status:*

Business Experience in Years:*

Number of Years in this Business:*

Business Type*

Contractor License Number: (if none please advice):

Carrier name information - past 4 years (if none please advise)
	Carrier	Policy Number (Optional)	Premium ($)
:
:
:
:

What percentage of work is:

Structure Type:
Residential:*
Industrial:*
Commercial:*


(Must Equal 100%)

Total MUST be 100

Construction Type:
New:*
Structural remodel/additions:*
Service/Repair:*
Non-structural remodel:*

(Must Equal 100%)

Total MUST be 100

Description of the Largest Current/ Planned Job:

Value of the Largest Current/ Planned Job: *

Description of the Largest Job in the last 3 years:

Value of the Largest Job in the last 3 years:

Additional Comments

Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough fields above, please enter them here.

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