Contractor General Liability Insurance Application "*" indicates required fields We couldn’t find your license in the database. You can still proceed with the application but we will need you to enter your information as it appears on your license. 1. Confirm Contact InformationEdit Contact InformationName: Business Name: License Number* not your license number?Business Name* Contact InformationContact Email* Contact Phone*Full Name* First Name* Last Name* Entity Type*CorporationSole OwnershipPartnershipJoint VentureLtd LiabilityTrustBusiness Address* Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Business Project Description*Percentage of WorkAll three Percentages of Work are required, and the total of the fields must be 100%Service & Repair %* Remodels %* New Contruction %* Percentage of ZoneAll three Percentage of Zone are required, and the total of the fields must be 100%Residential %* Commercial %* Industrial %* Business SizeGross Annual Receipts*Subcontractor CostsNumber of Field EmployeesField Employee PayrollUnderwritingMedical / School Facilities?Please make a selectionNo work on medical/school facilitiesI work on medical/school facilitiesClaim Activity Last 5 years ...Please make a selectionNo Claim ActivityA claim has been made against meI have sustained a loss due to a claimAn insurance company has denied me coverageAn insurance company has cancelled my coverageMaterial CostsCondo Work ...Please make a selectionNo Condo WorkYes, for the individual ownerYes, for the HOAYes, for both the Owner and the HOANameThis field is for validation purposes and should be left unchanged.
