Current Quote Status
Started:
09/18/2019
Incomplete Provide Basic Information
Incomplete Generate Applications
Incomplete Request to Bind
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Rachel Patterson, CIC

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If at any time you need assistance please contact Rachel Patterson, CIC at 800-342-5572 or rachel@jsausa.com

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Create GL & Workers Compensation Quote


Important Notice! Please verify the information below for a new quote for this risk. If you have any questions, please call us at 1-800-342-5572.

Basic Information
Applicant Name:
Agent Name:
Note: This is the name of the agent requesting the quote, NOT the agency name.
Agency Name:
Agency Phone:  -  - 
State:

What is the desired GL effective date? (This can be changed later)
What is the desired WC effective date? (This can be changed later)
How many GL losses has the applicant had within the last 3 years?
If number of losses is greater than zero, please specify the total amount of loss: $
How many WC losses has the applicant had within the last 3 years?
If number of losses is greater than zero, please specify the total amount of loss: $

Years in business:
Years experience:
Has the applicant’s workers compensation policy cancelled in the last year?  
 

Type of Business:

Does applicant perform any roofing work?  Yes
 No
Does the applicant perform any environmental services including but not limited to asbestos/lead/mold abatement, fire/smoke/water restoration?  Yes
 No
Does the applicant perform any waterproofing?  Yes
 No
Does the applicant perform and snow plowing?  Yes
 No
Does the applicant perform any Exterior Insulation Finishing Systems (EIFS) work?  Yes
 No
Does the applicant perform work on any aircraft or watercraft?  Yes
 No
Does the applicant perform work on barges, vessels, docks or bridges over water?  Yes
 No
Does applicant perform work on NEW, condominium, townhouse, row house, or tract home construction projects?  Yes
 No