Contractor Insurance

Disclaimer: Insurance transactions are not finalized without acknowledgement from a CONTRACTORS INSURANCE SPECIALISTS representative.
All quotes are subject to final underwriter/carrier approval.

*Contractor License Number:
*Business Name:
*Business Address:
*Owner/Contact Name:
*Number of Active Owners:
*Business Phone:
  Mobile Phone:
  Business Fax:
*Business Email:
*Estimated Gross Annual Receipts:
*Estimated Annual Field Payroll:
*Estimated Annual Sub-Out Cost:
Do you provide any new ground up construction?

Yes     No

*Claims in the Last Three Years?:
Yes     No
*Years Continuous Liability Coverage:
0     1     2     3
  Current Insurance Carrier:
  Policy Expiration Date:
*Number of Years in Business:
*Type of Work You Do:
Explain your Operations
*Request Additional Information
Check-mark which areas you would like more information on.
Commercial Truck Coverage
Workman's Comp (Simply check-mark for additional information).
Life Insurance
Health Insurance

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Your protection and security are our primary concern.

PO Box 2880
Lake Havasu City, AZ 86405
Local: (928) 846-3224
Toll-Free: (866) 941-3631
Fax: (928) 466-9122