Contractor Discovery Form Step 1 of 6 16% Contact Person's Name(Required) First Last Cell Phone Number(Required)Email Address(Required) Business Legal Name(Required)Organization Type(Required)Individual / Sole Proprietor / DBALimited Liability Corp (LLC)Limited Liability Partnership (LLP)Incorporated (Corp)OtherNumber of Owners(Required)1 Owner2 Owners / Partners3+ Owners / PartnersBusiness Website Address:Address(Required) 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?(Required) General Liability Property Coverage Commercial Auto Liability Worker's Comp Professional Liability Excess Liability / Umbrella Check all that applyDo you have an active contractor's license?(Required) Yes No Contractor License Numer:(Required)Type of license:(Required) Business ExperiencePlease provide the following information regarding your business experience. DO NOT include payroll for owner(s) below.Contractor Type(Required)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.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 No Name of Current Carrier:(Required)Have you had any claims or judgments filed against you in the last 5 years?(Required) Yes No Do you use any subcontractors?(Required) Yes No 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 No Do you generally use the same subcontractors?(Required) Yes No Does your subcontractor agreement include a hold harmless agreement clause?(Required) Yes No 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 No How often do you use a written contract with your customers?(Required) Always Sometimes Never Are you doing any tract home work?(Required) Yes No 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.CAPTCHA