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Pollution Insurance Quote

Pollution Insurance QuoteGravity Certs2024-08-17T17:18:03-04:00

"*" indicates required fields

Application Information

Applicant Name*

First Last

Email*

Phone*

Business Information

Proposed Policy Effective Date*

Legal Business Name*

Business Structure*

DBA

FEIN*

Business Address*

Street Address Address Line 2 City State ZIP Code

Mailing Address*

Same as Business Address

License Information

Contractors License or Application Fee Number

No license required

Classifications

Choose your primary class code. You may add up to 4 additional class codes to describe your business.

Class Code 1*

Class Code 1: % of Work*

Please enter a number from 0 to 100.

Add 2nd class code

Class Code 2

Class Code 2: % of Work

Please enter a number from 0 to 100.

Add 3rd class code

Class Code 3

Class Code 3: % of Work

Please enter a number from 0 to 100.

Add 4th class code

Class Code 4

Class Code 4: % of Work

Please enter a number from 0 to 100.

Add 5th class code

Class Code 5

Class Code 5: % of Work

Please enter a number from 0 to 100.

Total % of Work

Percent must add up to 100

Business Information

How many years has the applicant's current company been in business?*

Applicant's industry experience*

Insurance History*

Number of Active Owners*

Annual Gross Receipts*

Does Applicant Have Employees?

Yes

Number of Employees*

Please enter a number greater than or equal to 1.

Annual Employee Payroll*

Does Applicant Hire Subcontractors?

Yes

Annual Subcontractor Costs*

Percent of RESIDENTIAL work performed*

Please enter a number from 0 to 100.

Does Applicant perform residential work prior to the certificate of occupancy?

Yes

Percent of NEW work performed*

Please enter a number from 0 to 100.

*prior to approval for occupancy.

Percent of REMODELING work performed*

Please enter a number from 0 to 100.

*prior to approval for occupancy.

Total*

Percent must add up to 100

Please briefly describe your business*

File Attachments

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Max. file size: 12 MB.

Wrapping Up

How were you referred to us?

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Would you like a quote from a specific agent?

All the above information is accurate and true to the best of my knowledge*

Yes

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We are licensed to provide insurance services in Connecticut, Delaware, Georgia, Maryland, Maine, North Carolina, New Jersey, New York, Ohio, Oregon, Pennsylvania, South Carolina, and West Virginia.

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Fraud is a crime

If your application contains purposefully misleading, absent, or inaccurate information, you could be charged with fraud. Your insurance carrier could potentially void your policy, or you could face civil or criminal charges or penalties.

Any person who knowingly and with intent to defraud any insurance company or other person, files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent act, which is a crime.

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Pollution Insurance Quote

Application Information

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License Information

Classifications

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