Contractors Quote Request - Brown's Insurance Agency

Binding Agreement

(Required) I understand that any policy changes and quote requests are effective only when I have received a written confirmation.*

I agree

SMS Opt In

I agree to receive SMS messages about insurance (account notification and customer care) from Brown's Insurance Agency at the phone number provided above. The SMS frequency may vary. Data rates may apply. Text HELP to 1-703-368-0333 for assistance. Reply STOP to opt out of receiving SMS messages. Please review our Privacy Policy and terms of service here. *

Yes No

Your Contact Information

Business Name:*

First Name:*

Last Name:*

Title:

Email Address:*

Phone Number:*

How would you like us to follow up with you?*

Email Phone

Address

Street Address:*

City:*

County:*

State:*

Zip Code:*

Information About Your Business

Type of Business Entity:*

Please Describe your Business:*

Number of Full Time Employees:*

Number of Part Time Employees:*

Number of Supervisors?*

How long have you been in business?*

How many years of experience?*

Gross Income:*

Annual Payroll:*

Annual Sub-contracting costs:*

What % of your operation is:
General Contractor
Sub-contractor
And Construction manager:*

Please describe what work is performed by your employees?*

Please describe what work is performed by subs?*

What % of your work is residential?*

What % of your work is commercial?*

What % of your work is new construction:*

What % of your work is remodel work:*

If you work on apartments: What is the maximum # of apartment units?*

If you work on apartments: What is the maximum # of units per building?*

If you work involve new construction tract housing: What is the maximum # of homes in any one tract?*

Is there any information about your business you would like to add?

Information About Your Current Insurance

Do you currently have Commercial General Liability Insurance?*

Yes No

When does your current policy expire?

Who is the insurance company?

What is the approximate annual premium?

Please descibe any claims in the last three years. Please include dates, amounts and descriptions.

Other Coverage You May Need

Any other comments or information?

*Required fields:

This submission is a request. Insurance coverage changes and new coverages are not effective until we confirm that for you.

We will do our best to furnish a quote based on the information you provide. The more complete your information, the more accurate your quote will be.

Security:
The security of your personal information is important to Brown's Insurance Agency. Our site uses SSL encryption to ensure your personal information is sent securly to us.