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Steve
Stephen B. Groton -- Insurance Agent and Broker - Contractor Insurance Quote
110 South Rosemead Blvd Suite F
Pasadena, CA 91107
Across Rosemead Blvd from the Pasadena DMV.

CA License Number 0816642
626-584-6303

Contractor
General Liability Quote Form
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Business Name:
Mailing Address:
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E-Mail (REQUIRED):
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Business Underwriting Information
Type of operation:
 
Describe operations in detail:
 
License class:
 
License Number:
 
Social Sec. or Employer ID#:
 
Limit of Liability
Coverage Requested?
$100,000
$300,000
$500,000
$1 Million
 
Currently Insured? Yes No
Name of Carrier & how long insured?
Prior Claims? Yes No
Describe claims in detail:
 
Years in business:
 
Years experience in field:
 
Percentage of work residential:
 
Percentage of work commercial:
 
Number of Active Owners/Partners:
 
Number of Employees: 0   1   2   3+
 
Annual Employee Payroll: $
 
Annual Gross Sales: $
 
Do you subcontract work? Yes No
(If yes, what percentage of your work is subbed?)
Do you do foundation work? Yes No
Do you work on condos? Yes No
Any new construction? Yes No
Do you have a safety program? Yes No
 
Comments/Remarks:
 
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