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Local Phone:

Fax Number:

Office Address:
Specialty Insurance Agency
Slippery Rock Office:
567 Kelly Blvd.
Slippery Rock, PA 16057

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On-Line Roofing Contractor
General Liability Quote Form
One Simple Form - takes only 2-3 Minutes!

Your Name:
Mailing Address:
State: (Must be Pennsylvania)
E-Mail again for accuracy:
Fax (optional):
Business Underwriting Information
Type of operation:
Describe operations in detail:
License class:
License Number:
Limit of Liability
Coverage Requested?
$1 Million
Currently Insured? Yes No
Name of Carrier & how long insured?
Prior Claims? Yes No
Describe claims in detail:
Years in business:
Years experience in field:
Percentage of work residential:
Percentage of work commercial:
Number of Active Owners:
Number of Employees: 0   1   2   3+
Annual Employee Payroll: $
Annual Gross Sales: $
Do you subcontract work? Yes No
(If yes, what percentage of your work
is subbed, and what kind of work?)
Do you do foundation work? Yes No
Do you work on condos? Yes No
Employees paid over $18/hour? Yes No
Do you have a safety program? Yes No

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