Contractors Discovery Form in San Antonio, TX | My Insurance Group

Contact Person's Name(Required)

First Last

Cell Phone Number(Required)

Email Address(Required)

Business Legal Name(Required)

Organization Type(Required)

Number of Owners(Required)

Business Website Address:

Address(Required)

Street Address City State ZIP Code

What coverage is your business interested in?(Required)

General Liability

Property Coverage

Commercial Auto Liability

Worker's Comp

Professional Liability

Excess Liability / Umbrella

Check all that apply

Do you have an active contractor's license?(Required)

Yes

Contractor License Numer:(Required)

Type of license:(Required)

Business Experience

Please provide the following information regarding your business experience. DO NOT include payroll for owner(s) below.

Contractor Type(Required)

Please select the contractor type that best fits your business. On the next page, you can describe in more detail.

Year Business started(Required)

How many years of industry experience(Required)

Estimated Gross Sales / Revenue for the upcoming 12 months:(Required)

Estimated Payroll for the upcoming 12 months:(Required)

Number of employees:(Required)

Occupied Sq ft:(Required)

Do you have insurance currently?(Required)

Yes

Name of Current Carrier:(Required)

Have you had any claims or judgments filed against you in the last 5 years?(Required)

Yes

Do you use any subcontractors?(Required)

Yes

What is your estimated cost of subcontractors over the next 12 months including materials and labor?(Required)

Do you require your subcontractors to carry their own General Liability Insurance matching your same limits of liability?(Required)

Yes

Do you generally use the same subcontractors?(Required)

Yes

Does your subcontractor agreement include a hold harmless agreement clause?(Required)

Yes

Percentage of Commercial Work:(Required)

Please enter a number less than or equal to 100.

Percentage of Residential Work:(Required)

Please enter a number less than or equal to 100.

Percentage of work on New Construction:(Required)

Please enter a number less than or equal to 100.

Percentage of work on Existing structure/remodeling work:(Required)

Please enter a number less than or equal to 100.

Any work above 15ft or below 1ft surface?(Required)

Yes - Work above 15ft

Yes - Work below 1ft underground

How often do you use a written contract with your customers?(Required)

Always

Sometimes

Never

Are you doing any tract home work?(Required)

Yes

Briefly describe your business operations:(Required)

How did you first hear about us?(Required)

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(Required)

I consent & agree to the following:

The information given is true 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.

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Contractor Discovery Form

Business Experience