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Contractors Insurance Quote

Contact Information

First name:

Last name:

Business Name:

Mailing Address:

Email Address:

Telephone Number:

Fax Number:

Business Information

Type of operation:

Describe operations in detail:

License class:

License Number:

Limit of Liability Coverage Requested?

$300000

$500000

$1 Million

Currently Insured?

Yes

No

Name of Carrier:

How long insured? (years)

Prior Claims?

Yes (if yes describe below)

No

Describe claims in detail:

Years in business:

Years experience in field:

Percentage of work residential:

Percentage of work commercial:

Number of Active Owners:

Number of Employees:

Annual Employee Payroll: $

Annual Gross Sales: $

Do you subcontract work?

Yes

No

(If yes what percentage of your work is subbed and what kind of work?)

Do you do foundation work?

Yes

No

Do you work on condos?

Yes

No

Do you have a safety program?

Yes

No

Comments or Questions:

I understand that coverage
cannot be bound or altered by this
form submission request until the information
has been specifically
confirmed by one of our representatives
by phone or email.

Do not enter anything in this field:

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CA License # 0L64402
NV License# 3389852
CO License# 537023
AZ License # 7711229
OR License #7711229
TX License #2189320

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Harmony Insurance Agency
101 Hodencamp Rd, Suite 200
Thousand Oaks, CA 91360

Phone: 805-768-5142
Fax: 877-349-8810

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