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"Contractors Insurance Questionnaire"

Contractors Insurance Questionnaire
Please take five minutes of your time to find how much you can save. It is understood that this is not an application for insurance. There is no obligation and no sales person will call or visit me.
J. Byrne Agency, Inc.
5200 New Jersey Ave., Wildwood, NJ 08260
Phone 609-522-3406 / Fax 609-522-2844
Website: www.jbyrneagency.com

GENERAL INFORMATION
Last Name:
First Name:
Today's Date:
Street Address:
Apartment/Unit #:
   
City:
State:
Zip:
Name of Business:
Federal Tax ID:
E-mail:
    
Home Phone:
Business Phone:
    
Cell Phone:
Fax:
    

BUSINESS DESCRIPTION
Business Type:
Full time business:
Number of years in business:
Number of years experience:

Please describe your business in detail:

Number or Employees:
Total Annual Payroll:
Do you use subcontractors?
If yes, total amount paid to subcontractors
Commercial work percentage:
Residential work percentage:
Do you do roofing?
List any claims in the last 5 years:

TYPE OF INSURANCE YOU ARE INTERESTED IN
Please check all that apply:
 Liability Commercial Auto Tools / Equipment Workers Comp Group Health

WHO COMPLETED THIS FORM?
Full Name:
Today's Date:

FAIR CREDIT STATEMENT

Note: You must agree to the following terms in order to use this service.
Please read the statement below, carefully - before proceeding.

I Have Read the "Fair Credit Statement - and I AGREE to the terms set forth.

WARNING: Do NOT Continue without checking the box above.
You will not be able to continue and the answers to the questions you just answered may be lost.
 
Wildwood, NJ
5200 New Jersey Avenue
PO Box 1409
Wildwood, NJ 08260
Phone (609) 522-3406
Fax (609) 522-2844

Marmora, NJ
200 Route 9 South, Unit 1
Marmora, NJ 08223
Phone (609) 390-5566
Fax (609) 390-5577
Cape May Court House, NJ
1032 Route 9 South
Cape May Court House, NJ 08210
Phone (609) 465-7710
Fax (609) 465-9346
Cape May , NJ
917 Madison Avenue
Cape May, NJ 08204
Phone (609) 884-3333
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