Whitney Group - General Contractors Form

The Whitney Group, 2701 NW 2nd Avenue, Suite 213, Boca Raton, FL 33431
561-210-8715 / 877-210-8715 / Fax: 561-210-8716

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General Liability

Please note that completion of the following request for information does not constitute the purchase of insurance. No coverage may be added, changed or bound as a result of submitting this request for information or quotation of insurance. All coverage must be confirmed by the agency in writing subject to an acceptable signed application meeting the underwriting guidelines of the Insurance Company.
	*	= required field

Your Name:	*
Company Name:
Address:
Phone Number:	*
Fax Number:
Email Address:	*
Number of Active Owners:
Number of Supervisors:
Payroll for Supervisors ($):
Number of Trade / Labor Employees:
Weekly Payroll for Trade / Labor Employees ($):
Describe Typical Work Trade / Labor Employees Perform:
Estimated Annual Gross Sales:
Estimated Annual Cost of Subcontractors:
% of Residential Construction Performed:
% of Commercial Construction Performed:
Name of Current GL Insurance Company:
Expiration Date of GL Policy:
Have you had General Liability Claims within 5 years?		Yes No
Comments: