Hollingsworth Insurance Services

Artisan Contractor
     We would like to provide you with a free, no-obligation artisan contractor insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

Agent Information
Agent Name:
Phone #:   Fax #:
Email Address:
  (Note: A copy of this submision will be sent to the email
  address entered in this field, so please enter correctly)

General Information
Name Insured(s):
Applicant DBA:
Contact Person:
Physical Address:
City: State: Zip:
Mailing Address (if different):
City: State: Zip:
Insured Telephone:

Receipts/Employee/Payroll Information
Proposed Effective Date:
Description of operation:
Projected Gross Receipts
Annual Gross Receipts (past 3 years)
Next 12 months
Number of owners/partners:
Number of: Full time employees:     Part time employees:
Total Employee Payroll:
(no owner, clerical or sales)
$     Sub-Contracting Costs: $
Business Status:

Business Information
Applicants business experience in years:
Number of years in business:
Type of business:
Contractor license number:   (if none please advise)
Carrier name information - past 4 years   (if none please advise)
Policy Number
What percientage of work is:
Structure Type
(must equal 100%) 
Construction Type
Structural remodel/additions:
Non-structural remodel:
(must equal 100%) 
Description of Largest Current/
Planned Job:
Value of that job: $
Description of Largest job last 3 years:
Value of that job: $

Additional Comments
Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough fields above, please enter them here.

Please click on the "Submit Application" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.


Online Forms by ENHANCED Web Services
This Artisan Contractors Form Copyright © 2001 - by ENHANCED Web Services