General Contractor Liability EQ Insurance Services Online

To request more information, please complete the form below.
*Bold fields are required*

*Agent Email:*
*Agent Name:*
*Agent Phone:*	Applicant Information
*Insured Name:*
*Effective Date:*
*Has the insured had any* *claims in the last 3 years:*
*Address:*
*City:*
*State:*
*Zip Code:*
*Select the type of business:*
*Enter the number of owners/partners:*
*Enter the total payroll for the owner(s):*	If you select Sole Proprietor or Multiple Partners then you cannot edit owners/partners payroll. If you select Corporation then the number of owners/partners is not applicable however, you must enter the owners payroll. If the owners payroll entered is less than the minimum payroll for the state we will set the owners payroll to the mimimum for that state. For all business types the owners payroll will be added to direct employee payroll which is entered on the next screen.
Enter direct employee payroll:
Enter uninsured subcontractor payroll:
Enter total insured subcontractor cost:
Estimated number new home startups for policy period:
Annual estimated gross receipts:
*Select liability limit:*
Had prior insurance coverage?
Optional scheduled Inland Marine indication?
	By clicking the submit button I understand that I will receive an INDICATION ONLY. Coverage is not bound until our General Agent, Appalachian Underwriters contacts you by phone, fax, or email.