Contractor Intake Form Step 1 of 3 - Contact Info 0% Pick the option that applies to you:* I am submitting this form for one of my clients I am a potential client Name of the referral source:* Owner's Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Enter Email Confirm Email Company Name* Company Legal Structure*Sole ProprietorCorporationLimited Liability CompanyWhat year was the company established?*Company Tax ID* Industry*Accounting/FinanceAdvertising/Public RelationsAerospace/AviationArts/Entertainment/PublishingAutomotiveBanking/MortgageBusiness DevelopmentBusiness OpportunityClerical/AdministrativeConstruction/FacilitiesConsumer GoodsCustomer ServiceEducation/TrainingEnergy/UtilitiesEngineeringGovernment/MilitaryGreenHealthcareHospitality/TravelHuman ResourcesInstallation/MaintenanceInsuranceInternetJob Search AidsLaw Enforcement/SecurityLegalManagement/ExecutiveManufacturing/OperationsMarketingNon-Profit/VolunteerPharmaceutical/BiotechProfessional ServicesQA/Quality ControlReal EstateRestaurant/Food ServiceRetailSalesScience/ResearchSkilled LaborTechnologyTelecommunicationsTransportation/LogisticsOtherPlease describe business activity*Square feet occupied*Gross Annual Sales*Estimated Subcontracting Costs*Input "0" if noneNumber of Employees*Estimated Annual Payroll*Desired GL Limits1M / 1M / 1M1M / 2M / 2M1M/ 2M / 2M2M / 2M/ 2M3M / 3M / 3M4M / 4M / 4M5M / 5M / 5MOtherIs "A-Rated" coverage required?* Yes No Do you offer any of the following benefits?*Check all that apply No, I don't currently offer any benefits Major Medical Vision/Dental Life Insurance/Disability Insurance Accident/Critical Illness Commuter Benefits Retirement Pan Coverage currently in place*Check all that apply General Liability Professional Liability Workers Compensation Commercial Auto Commercial Umbrella Employment Practices Liability Cyber Liability Liquor Liability Food Liability None of the above Estimated Total Insurance Premium (across all policies)*"0" if you have no insuranceCopies of current policiesPlease upload your most current insurance policy coverage declarations pages in PDF format so we can see the exact coverage limits you'd like us to compare. These can be easily downloaded from your online profile with your current provider. Drop files here or Select files Max. file size: 98 MB.
