"*" indicates required fields Step 1 of 8 12% General Business InformationBusiness Legal Name* DBA (if applicable) Organization Type*Individual / Sole ProprietorLimited Liability Corp (LLC)Limited Liability Partnership (LLP)Incorporated (Corp)OtherContact Person's Name* First Last Contact Phone Number*Contact Email* Business Website Address FEIN*DO NOT enter SSN. If no FEIN, enter 123456789. Primary Location Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mailing address: Same Different Mailing Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code What coverage is your business interested in?* General Liability Property Coverage Worker's Comp Professional Liability Excess Liability / Umbrella Check all that applyDoes the business perform work as an artisan contractor?* Yes No Artisan Contractor QuestionsContractor Type*Cabinet / Countertop Install - No New Tract Home WorkCarpentry (Patios, decks, finishing install - No New Tract Home WorkCommercial RemodelingConcrete / Flat work ONLY - No New Tract Home WorkConcrete / Foundation - No New Tract Home WorkDrywall Install, Tape & Float - No New Tract Home WorkElectrical - No New Tract Home WorkExterior Painting (including interior painting) - No New Tract Home WorkInterior Painting ONLY - No New Tract Home WorkInsulation InstallationFloor Covering Install - No New Tract Home WorkFraming - No New Tract Home WorkGeneral Contractor (100% subcontract work)HVAC - No New Tract Home WorkPlumbing - No New Tract Home WorkResidential RemodelingRoofing - No New Tract Home WorkSolar Energy ContractorOTHERPlease select the contractor type that best fits your business. On the next page, you can describe in more detail.Do you have an active contractor's license?* Yes No License Number:* Any work performed below ground or above 15ft?* None Above 15 ft Underground Both Do you use a written contract with your customers? Always Sometimes Never Commercial Work %*Please enter a number less than or equal to 100.Residential Work %*Please enter a number less than or equal to 100.New Construction %*Please enter a number less than or equal to 100.Remodel %*Please enter a number less than or equal to 100. Additional Business InformationDescription of business operations:*Year Business Started*20242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924prior to 1924Years of Industry Experience*Number of Owners*1 Owner2 Owners / Partners3+ Owners / PartnersNumber of staffed locations:*Only oneMultiple locations but only in TexasMultiple locations in multiple statesOccupied Sq ft:* Est. Annual Gross Sales/Revenue*Number of Employees*Estimated Annual Payroll*Include owners/officers in WC coverage?* Yes No Are subcontractors used?* Yes No Subcontractor QuestionsDoes your subcontractor agreement include a hold harmless clause?* Yes No Do you require subcontractors to maintain General Liability Insurance matching your limits of liability?* Yes No Do you generally use the same subcontractors?* Yes No Est. annual cost of subcontractors (incl. materials & labor)* Current InsuranceDoes the business currently have insurance?* Yes No Have you had any claims or judgments filed against you in the last 5 years? Yes No Current Insurance Company:* Expiration Date:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Please upload a copy of your current insurance declarations: Drop files here or Select files Max. file size: 5 MB. Why are you shopping for insurance?* New Venture Price Bad Claims Experience Poor Customer Service Experience No Local Representation Other How did you first hear about us?* Current Customer Family/Friend Referral Channel Partner Referral (Mortgage Broker, Realtor, Other Insurance agent) Google Search Social Media Post (Facebook, Instagram, Twitter) Local Event Other Consent* I consent & agree to the following:The application information is true and correct to the best of my knowledge. By submitting this request you are authorizing My Insurance Group, its affiliates and carrier partners the access to pull the necessary reports (i.e. claims, credit, and loss history) to confirm the data submitted. Submitting your quote request does not constitute a binding confirmation of a new or revised insurance coverage. My Insurance Group is committed to respecting your privacy and communication preferences. So that we may remain compliant with state and federal regulations, we need your expressed permission to communicate with you through phone, text and email as needed. You may opt-out of all future communication at any time by making your preferences known to us.CAPTCHA