Contractor Application | XS Specialty, LLC

Commercial Contractors General Liability Insurance Quotes

Please take a moment to fill out the form below and one of our local insurance agents will contact you with a free, no-obligation quote. This information will be kept confidential and will be used for quote purposes only.

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Quote Identifier*
Requested Policy Period
From*
Date Format: MM slash DD slash YYYY
To*
Date Format: MM slash DD slash YYYY
Insured Information
Applicants (List All Owners)*

Press the "+" symbol to list another owner.
DBA*
Business Type*
- Individual
- Partnership
- Corporation
Company Contact*
Company Contact's Phone*
Business Address*
Street Address Address Line 2 City State ZIP Code
Mailing Address*
Street Address Address Line 2 City State ZIP Code
Agency Information
Agency Name*
Producer's Name*
Agency Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Fax*
Email*
Producer Code*
New Venture Section
Years Under Current Name*
If more than 3 years under current name, please proceed to loss history section.
Date Business Established*
Date Format: MM slash DD slash YYYY
Years of Related Experience*
List All Business Names Applicant/Owner Has Owned In Past*

Press the "+" symbol to list another business.
Brief Summary of Prior Experience In Same Field*
Loss History
Number of General Liability Claims Within Last 3 Years*
Total General Liability Claims (Paid and Reserve) Within Last 3 Years ($)*
Number of Current Open General Liability Claims*
Have You Had More Than One Construction Defect Claim?*
- Yes
- No
* If losses apply please attach currently valued loss runs including a complete description of all losses.
Prior Carrier Information
List 3 Most Recent Carriers*
Carrier Policy Number Eff-Exp Date Total Premium

Press the "+" symbol to list another carrier.
Program Specific Information
Limits Requested*
Damage to Rented Premises/Medical Exspense*
- 100,000/5,000
Detailed Description of Operations (Must Include All Operations)*
New Construction Breakdown (Commercial vs Residential)*
Commercial (%) Residential (%)
Remodeling Breakdown (Commercial vs Residential)*
Commercial (%) Residential (%)
Number of Owners*
Number of Employees*
Direct Payroll Excluding Owners, Principals, Sales, and Clerical*
Insured Subcontractor Costs*
Uninsured Subcontractor Costs*
Gross Receipts Last Year*
Estimated Gross Receipts This Year*
* Subcontractors must carry limits equal to or greater than applicant to be considered insured.
The total cost of all work let or sublet in connection with each specific project including:

1. The cost of all labor, materials and equipment furnished, used or delivered for use in the execution of the work, however, do not include the cost of finished equipment installed but not furnished by the subcontractor if the subcontractor does no other work on or in connection with such equipment; and

2. All fees, bonuses or commissions made, paid or due.

The rates apply per $1,000 of Total Cost.
List all Operations Performed by Uninsured or Underinsured Subcontractors*
Expiring Year*
Direct Payroll (Exclude Owners) Total Subcontractor Cost Gross Receipts
First Prior Year*
Direct Payroll (Exclude Owners) Total Subcontractor Cost Gross Receipts
Second Prior Year*
Direct Payroll (Exclude Owners) Total Subcontractor Cost Gross Receipts
Questionnaire
Further information may be required based on answers below.
Is this a new venture?*
- Yes
- No
How many years in business?*
- Yes
- No
How many years experience in the construction field?*
- Yes
- No
Has the risk had prior insurance for 12 consecutive months?*
- Yes
- No
Has any coverage been cancelled, non-renewed, or lapsed in the last 3 years?*
- Yes
- No
Have you had any losses over $5,000 in the last 3 years?*
- Yes
- No
How many years has this contractor operated loss free? (Loss Runs Required)*
- Yes
- No
Does the contractor comply with all state licensing requirements?*
- Yes
- No
Does the contractor allow others to operate using their license?*
- Yes
- No
Does the applicant perform any work in the state of New York?*
- Yes
- No
Has any owner, officer, principal, or partner been convicted of a felony?*
- Yes
- No
Is the applicant currently in bankruptcy?*
- Yes
- No
Any new construction, repair or remodeling of Condominiums, Condo Conversions, Tract Housing, or Townhomes?*
- Yes
- No
Any exterior work over three (3) stories in height?*
- Yes
- No
Any work related to underground utility, tunneling, railroad, street, road, bridge, or dam construction?*
- Yes
- No
Any installation or erection of playground equipment, bleachers, or stages?*
- Yes
- No
Any leasing or rental of equipment to others?*
- Yes
- No
Any blasting operations?*
- Yes
- No
Any work for industrial, petroleum, chemical, or mining facilities?*
- Yes
- No
Any hazardous material abatement or environmental remediation?*
- Yes
- No
Any remediation work involving smoke, fire, water, or earthquake damage?*
- Yes
- No
Any grading and excavation on slopes of greater than 30 degrees or work on retaining walls over 6 feet in height?*
- Yes
- No
Any work performed at hospitals, senior housing, assisted living, retirement homes, or schools?*
- Yes
- No
Does this contractor install, repair, or maintain grain elevators, traffic lights, underground storage tanks, skylights, or EIFS?*
- Yes
- No
Are subcontractors required to carry limits equal to the applicant?*
- Yes
- No
Are subcontractors required to name applicant as an additional insured under their own GL policy?*
- Yes
- No
Are subcontractors required by contract to hold the applicant harmless?*
- Yes
- No
Will the insured maintain certificates and contracts related to subcontractors for a period of 5 years?*
- Yes
- No
Is the Executive Supervisor only engaged in administrative or managerial responsibilities for construction projects?*
- Yes
- No
Is the Executive Supervisor working as a foreman or job superintendent?*
- Yes
- No
Is the Executive Supervisor engaged in any physical activity related to the construction process?*
- Yes
- No
Any installation of WOOD framed doors or windows?*
- Yes
- No
Any work on skateboard parks, airports, or underground?*
- Yes
- No
Any guinting, pile driving, excavation, sewer work, or underpinning?*
- Yes
- No
Any concrete cutting, boring, or drilling?*
- Yes
- No
Does the risk own any other businesses?*
- Yes
- No
Please explain any of the following - Losses over 5k, cancelled/non-renewed/lapsed coverage in the last 3 years, or no prior insurance in the last 12 months:*
Please explain any yes ANSWER or enter comments:*
Fraud Warning*
- I Agree
It is a crime to knowingly and intentionally attempt to defraud an insurance company by providing false or misleading information or concealing material information during the application process or when filing a claim. Such conduct could result in the policy being voided and subject you to criminal and civil penalties.

By continuing with this bind/application process, you and your business partners confirm that the facts in the application are true and that all premiums due will be remitted.

I have read and agree with these statements, and acknowledge the above Fraud Warning. I hereby declare that the application for insurance is true and I have not misstated any material fact and that I agree that all premiums due will be remitted.
Comments
This field is for validation purposes and should be left unchanged.

Carrier	Policy Number	Eff-Exp Date	Total Premium

Commercial Contractors General Liability Insurance Quotes

Requested Policy Period

Insured Information

Agency Information

New Venture Section

Loss History

Prior Carrier Information

Program Specific Information

Questionnaire