Mikkelsen Insurance Services

Preliminary information needed for Artisan Contractors insurance premium indication! Please complete all blanks. In addition, please fax 5 years current valued loss runs to 209-839-8705.
If you do not have coverage at this time or you are a Contractor with an A or B license
please call 800-444-3199. California Only! (Our Privacy Statement)
Name:
Business Name:
Address:
City:
County CA Zip code:
Phone:
Fax:
E-mail address:
Current Carrier:
Expiration date:
1. C.L. Number: Type? Years in bus? Total yrs. exp.?
Company structure: (Indiv. )(Corp. )(Partnership )?
2. Describe your normal operations and please be as detailed as possible:

3. What are your total estimated gross receipts for the coming year:
Gross revenues: Direct payroll: Subcontract costs:
Gross Revenues Payroll Sub. costs
2006
2005
2004
What trades do you subcontract to others?
4. Number of employees: Full time: Part time: How many active owners?
5. Percentage of work performed in:
A:
Residential: % Condos: % Apartments: %
Commercial: %
Must = 100%
Do you do work on tract homes: Yes or No (New construction)
B:
New Construction: % Remodeling: % Demolition: %
Repairs: %
Must = 100%
6. Describe your five largest projects (jobs) over the past five years including values and time duration.
7. What limits do you need quoted? Please select
8. Any claims or losses during the last five years? (Please give complete details)

9. Has any insurance been canceled or non renewed in the last three years?

If yes please give details.

10. Other coverages wanted/needed?
11. Best time to contact you for any additional information needed:

Please complete the form and press the "Send" button, or if you prefer you may print the form and Fax it to us at 209-839-8632

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