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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 Georgia)
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 (full & part time):
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

 
Other Coverages You Would Like Information On: Tool & Equipment Floater Commercial Vehicle
Bonds, License/Performance
Workers Compensation
Builders Risk Insurance
 
Comments/Remarks:
 
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Thank you for filling out this form COMPLETELY!

DISCLOSURE "In connection with this application for insurance, some carriers may review your credit report, or obtain or use a credit based insurance score based on the information contained in that report. We may use a third party in connection with development of your insurance score."

CHECK THIS BOX FOR QUOTE RELEASE - This information has been reviewed with the customer and agreed upon. We value your privacy and will release NO personal information you give us to ANY other party, at any time, and make every effort to keep your information confidential.

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James M. Swain & Associates, Inc. . PO Box 365 . Baxley, GA 31515
Toll Free: 800-870-5830 . Local Phone: 912-367-3601 . Fax: 912-367-7152
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