Contractor’s Insurance Quote Request
Please provide the following as accurate as possible: (Enter 0 for the past year if it is your firstyear)
a) Past year
b) Next year estimate
What is the breakdown for work performed by you or on behalf of you? (Enter 0 if does not applyto you)
% of revenue
By submitting the above-mentioned information, the applicant declares that all statements made in the questionnaire and the information contained in documents submitted with it are true.
Submitting of this document does not bind the applicant to complete the insurance, but it is agreed that the questionnaire shall be the basis of the contract, should a policy be issued.