* =Required Fields

* Business Name
 
Premises Address
City
State
Zip
 
* Email
Contact Name:
Phone
Fax
Years in Business:
 
Number of Employees:
Payroll (not including owners): $
Estimated Gross Receipts: $
 
Current Insurance Company:
Policy Expiration Date:
(mm/dd/yyyy)
 
Losses past 3 years: Yes No
Amount paid for each loss: $
Description of losses or loss runs:
 
Contractor Type:

Percentage of work that is new construction:
Percentage of work that is remodeling:

Select all that apply to your Illinois business: Work underground
Work above 15 feet
Work tunneling or trench work below 3 feet
Install automatic sprinkler or fire suppression systems
Install fire alarms or smoke detectors
Install or repair gas mains
Apply exterior insullation finish
Remodeling involving load baring walls, foundation, or other structural changes
Require out of state travel
Use Subcontractors
Other Work Type

Illinois Contractors Insurance Coverage Amounts Desired:

Liability Limit Desired:
Property Damage Deductible:
Or choose other liability limit amount: $
Endorsements Desired:

Illinois Contractors Equipment Insurance Coverage Desired:

Equipment Value: $
Tools Value: $

Additional Information or Comments

* Enter Security Code