General Liability Quote Request

IMPORTANT NOTICE

 1. This general liability quote request applies only to the states of Oregon and Washington. Do not fill out this form if you are not located, or do not operate your business, in Oregon or Washington.

 2. Insurance companies may use information from you and other sources which pertains to the ability of you or your business to meet financial obligations. By submitting this quote request, you are giving permission for the possible access and review of your credit history and credit rating. This authorization extends to Beaverton-Tigard Insurance and to any insurance company that it may contact for the purpose of obtaining coverage for you and/or your business. This authorization is to remain in force until you choose to rescind it in writing.

 3. No coverage will be started by submitting this form. Coverage may be placed in force only after you decide to purchase it from us, and then after you sign an application and pay the initial premium.

 4. Submitting the following quote request constitutes your agreement with the above statements. We will contact you within two business days after we receive your request. If you have questions concerning this notice or about the following form, please call us at 503-620-0230 or toll-free 1-888-620-0230.

Contractor Liability Quote Request
  1. Contact Person
    Invalid Input
  2. Phone Number
    Invalid Input
  3. Fax Number
    Invalid Input
  4. Business Entity
    Invalid Input
  5. Name of Business
    Invalid Input
  6. DBA
    Invalid Input
  7. Business Website, if any
    Invalid Input
  8. Federal Employer Tax ID Number
    Invalid Input
  9. Email
    Invalid Input
  10. Year Business Started
    Invalid Input
  11. How Many Years Experience
    Invalid Input
  12. Street Address
    Invalid Input
  13. State
    Invalid Input
  14. ZipCode
    Invalid Input
  15. City
    Invalid Input
  16. Mailing Address If Different
    Invalid Input
  17. Current Insurance Company
    Invalid Input
  18. Expiration or Renewal Date
    Invalid Input
  19. Contractor Registration Number
    Invalid Input
  20. Business Description (What Do You Do?)
    Invalid Input
  21. Any Claims or Losses in Past 5 Years? Describe
    Invalid Input
  22. Liability Occurrence Limit Desired
    Invalid Input
  23. Liability Aggregate Limit
    Invalid Input
  24. Names of Owners and Percentage of Ownership
    Invalid Input
  25. Number Of Employees
    Invalid Input
  26. Estimated Annual Payroll
    Invalid Input
  27. Estimated Annual Gross Receipts
    Invalid Input
  28. Percent Of Work SubContracted
    Invalid Input
  29. Percentage Of Residential Work
    Invalid Input
  30. Percentage Of Commercial Work
    Invalid Input
  31. Percentage Of Work On New Construction
    Invalid Input
  32. Percentage Of Work On Existing Construction
    Invalid Input
  33. Do you work in new residential subdivisions?
    Invalid Input
  34. If so, what is the size of the subdivision or tract?
    Invalid Input
  35. % Of Work in Apartments, Condos, Townhouses
    Invalid Input
  36. EstimatedAnnualSubCosts
    Invalid Input
  37. Describe any additional insureds
    Invalid Input
  38. Describe any waivers of subrogation needed
    Invalid Input
  39. Additional information or comments. If canceled, explain the reason.
    Invalid Input
  40. Re-type the security field numbers in the box.
  41. Security Field
    Security Field The Security code you typed did not match. Please click "Refresh" and try again.
  42. To keep a copy of this form, please Print before Submitting
  43.   

Network with BTIA

Follow us on Twitter & Facebook:
BTIA on Facebook  BTIA on Twitter
Share this page with your network:
AddThis Social Bookmark Button

Questions?

If you have questions concerning this information, please call us at 503-620-0230, or come in.

Llámenos ya al 503-620-0230.