Contractor's Insurance Inquiry Form (Pennsylvania)

Contractor's Insurance
(Pennsylvania)

Business Name:
Contact Name:
Mailing Address:
City:	State: Zipcode:
Phone Number:	Fax Number:
E-Mail Address:

Business Type:

Year Started Business:
Years Experience:
(if less than 3 years in business)

Required for Quote:

Annual Payroll:
$

# of Employees
(including yourself &partners):

Paid to Sub-Contractors:
$

Annual Gross Sales:
$

Current Policy Information:

Your current insurance company: Policy Expires:

Type of Contractor:

If Janitorial, please provide the service that you provide

General Cleaning (dusting, floor cleaning, restroom cleanup)
Carpet Cleaning
Snow Removal
Chimney Cleaning
Pest Control/Extermination
Fire Restoration
Maid/Housekeeping Services
Degreasing Service (restaurant grease traps/Ansul Systems)
Industrial Cleaning
Ceiling Tile Cleaning

Elevator Maintenance
Parking Lot Maintenance
Death Scene Cleanup
Building Security
Cleaning/Renovating Outside Building Walls
Building Construction or Renovation
Landscaping (including lawn mowing
Floor Waxing and Buffing
Exterior Window Cleaning above 1st Floor
Heating/Ventilation/Air Duct Cleaning or Service
Aircraft Service and maintenance

Describe any other services that you perform, that are not listed above:

If you have any commercial customers, please indicate the nature of their businesses:

Property Coverages

Property to be Insured Value Deductible

Building (Construction: )

Contents (on your premises)

Misc. Tools/Equipment (no item over $ 500)

$ 250 Deductible

Scheduled or Listed Tools/Equipment (Items over $ 500)

Materials on the jobsite

Liability Coverages

Liability Limit per Occurrence:

Insurance Losses in the Last 3 Years

Date
What Happened?

M c G R A T H I N S U R A N C E G R O U P

4170 William Penn Highway                     Murrysville, PA. 15668-1890
(724) 327-8474                      (Fax) 327-7911
Toll Free: 1-800-977-2999                (Fax) 1-888-800-0034

Property to be Insured	Value	Deductible
Building (Construction: )
Contents (on your premises)
Misc. Tools/Equipment (no item over $ 500)		$ 250 Deductible
Scheduled or Listed Tools/Equipment (Items over $ 500)
Materials on the jobsite