Carter & Company, L.L.P.

 

 

 

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Electrician's General Liability Insurance Quote
For the fastest and most accurate insurance quote, please provide as much information possible in the form below. This information will be kept confidential and will be used for quote purposes ONLY!

General Information
Name of Business:
Inspection Contact Name:
Mailing Address:
City: State:    Zip:
Location Address:
City: State:    Zip:
Business Phone:    Fax:
Contact Email Address:
*Social Security # or *FEIN
*Required by insurance companies in order to quote
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: $
Do you collect certificates of insurance at a $1,000,000 limit?:
  Yes     No

 

Receipts / Payroll / Dollar Value Info

Gross receipts for the past 3 years: 
and the next 12 months: 
(3rd yr prior) $     (2nd yr prior) $
(Last 12 mths) $  (Next 12 mths) $
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 incl. all materials, labor & equipment: 
   $
Describe any projects underway or planned for the next year, including values below:

Miscellaneous and Legal Info

Have you ever performed ground up construction involving condominiums, townhouses, apartments, or single family tract developments of two (2) or more?: 
  Yes   No
Have you ever been named in litigation regarding faulty construction?: 
  Yes   No
Are there any claims or legal actions pending?: 
  Yes   No
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?: 
  Yes   No

 

Coverages Desired
General Aggregate Limit of Liability Desired:
  
Each Occurrence Limit of Liability Desired:

 

Underwriting Questions

Do you operate a bucket truck?
Yes    No

Do you work on fire alarms, burglar alarms, automatic sprinkler design, install ore repair emergency back-up equipment?

Yes    No

Do you work near or in airports or hospitals?

Yes    No

Do you work in or around nuclear plants, power plants or petrochemical plants?

Yes    No

Do you work in or around dams, bridges or rivers?

Yes    No

Do you draw plans, designs or specifications for others?

Yes    No

How many years of experience do you have in this class of work?

Do you perform any other type of work?

Yes    No

What other types of work do you perform (if any)?

What percent of your payroll is associated with other  types of work?

Do you subcontract any work to others?

Yes    No

Do you get certificates of insurance from subcontractors?

Yes    No

What type of work do you subcontract to others?

What is the total annual estimated cost of work subcontracted to others?

During the last three years, has any company cancelled, declined or refused to renew your insurance?

Yes    No

Is at least 75% of your payroll for electrical work?

 Yes    No

Does your cost of hiring subcontractors exceed 25% of your receipts?

 Yes    No

Do you have 2 or more years in business OR 5 years of related experience?

 Yes    No

Do you have over 10 employees?

Yes    No

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

    

 

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