Agent Info:
Name : Denis Mehulic
License ID : 0L58079
Phone : (408) 674-3569
Email : [email protected]
Address : ste 201 1095, San Jose, California, 95136

Artisan Contractor Liability

  • Applicant
  • Business
  • Coverage
  • Prior Carrier
  • Miscellaneous
  • Finish

Applicant

First Name *
Last Name *

Where should we send your quote?

Email *
Phone *

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Business

Business Info

Business /​ Company Name *
Founding Date *
DBA (If Applicable)
FEIN (If Applicable)
Organization Type
Business Address
Address *
City *
State *
Zipcode *

Internal

Type of Business *
Specify business *
Number of Years in the Business
Business Status *
Specify Business Status *
Annual Payroll *
Annual Revenue *
Full-Time Employees
Part-Time Employees
Description of Business

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Coverage

Coverage Status

Proposed Effective Date
Contractor License *

Projected Gross Receipts

For the next 12 Months *

Annual gross receipt ( Past 3 Years)

2021
2020
2019

Employees and Partners

Number of Owners /​ Partners *
Number of Full Time Employees *
Number of Part Time Employees *
Total Employee on Payroll *

(No owner, clerical or sales)

Sub-contracting Costs

Percentage of Work

Structural
Residential *
Industrial *
Commercial *
Construction Type
New Construction *
Remodel /​ Additions *
Service /​ Repair *
Non-Structural Remodel *

Current / Planned Jobs

Please fill in as much as you can

Description of the Largest Current/​Planned job
Value Of The Largest Current/​Planned Job
Description of the Largest Current/​Planned job in the last 3 years
Value Of The Largest Current/​Planned Job in the last 3 years

Additional Policies

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Prior Carrier

Carrier 2021

Carrier Name *
Policy Number
Premium

Carrier 2020

Carrier Name *
Policy Number
Premium

Carrier 2019

Carrier Name *
Policy Number
Premium

Carrier 2018

Carrier Name *
Policy Number
Premium

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Miscellaneous

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