Strategic Insurance Services, LLC - Contractors Inquiry Form

Please complete the following information.
Company Name *
Contact Person *
Company Address
Address *
City *
State/Province *
ZIP/Postal Code *
Country *
Phone *
Email *
example@example.com
Website
FEIN# *
Birth Date *

Month Day Year
Current Insurance Carrier *
Current Insurance Expiration Date
Year Business was Established *
Years of Experience *
Are you an HBA Member? *

Yes No
Do you use a 10-2 Structural Warranty? *

Yes No
Company:
Do you have a Safety Program? *

Yes No
Do you have a Builder License? *

Yes No
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Do you us a program that tracks Certificates of Insurance from Subs? *

Yes No
Projected Gross Sales Revenue for the next 12 months *
Projected Sub-Contractor Costs *
Describe the jobs you intend to complete *
(Urban infill, Custom, Production, Multifamily, For Sale, Rentals, etc)
Are you interested in Builders Risk? *

Yes No
Do you need Property Coverage? *

Yes No
Property Coverage Information
Describe the property that needs to be covered.
(Vacant Land, Vacant Home, Office and Contents, etc.)
Property Address
Address
City
State/Province
ZIP/Postal Code
Country
Storage Footage
Year of Building
Is building owned or leased?

Owned Leased
Alarm/Fire System?

Yes No
Do you have an additional Office or Sales Trailer?

Yes No
Values
Do you have any tools or heavy equipment?

Yes No
Value
Office Contents: How much would you like to insure for?
Specify location of contents
If there is anything unique in the office (i.e. art, antiques, etc) please list
Do you have sales staff, designers, or architects as employees?

Yes No
Do they carry their own Professional Liability or E&O Coverage & what are their limits?
Should be Empty:

Property Coverage Information