Contractors & Gig Workers Please complete the form below. Business Information Insured Name (Company Name) * Owner Name * First Name Last Name Business Type * Individual Partnership Corporation LLC Other EIN/SS * Business Description * Date of Formation * MM DD YYYY Email * Insured Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Proposed Effective Date * MM DD YYYY How long has your company been in business? * Have you had any insurance claims in the last five years? * Yes No Office Information What is your annual revenue? Is your workspace a home office or commercial location? Yes No General Liability Limits General Aggregate $1,000,000 $2,000,000 $3,000,000 $5,000,000 $10,000,000 $15,000,000 Products/Completed Operations Aggregate $1,000,000 $2,000,000 $3,000,000 $5,000,000 $10,000,000 Each Occurance $1,000,000 $2,000,000 $3,000,000 $5,000,000 $10,000,000 Personal Advertising Injury $1,000,000 $2,000,000 $3,000,000 $5,000,000 $10,000,000 Damage to Premises Rented $1,000,000 $2,000,000 $3,000,000 $5,000,000 $10,000,000 Medical Payments (anyone) $1,000,000 $2,000,000 $3,000,000 $5,000,000 $10,000,000 Carrier Information (if applicable) Current Carrier Policy Number Premium Effective Date MM DD YYYY Thank you for your submission. One of our agents will contact you shortly.
