Welcome to CCRoy Insurance Brokers

PLEASE FILL OUT THE FOLLOWING INFORMATION AND PRESS THE SUBMIT BUTTON
Company Name A value is required.Exceeded maximum number of characters.
Contact Name A value is required.Exceeded maximum number of characters.
Cell Invalid format. Phone A value is required.Invalid format.
Fax Invalid format. E-Mail A value is required.Invalid format.
www. Exceeded maximum number of characters.
Contractor's License # 6-digit license is required. 6-digit license is required. Years in Business A value is required.Exceeded maximum number of characters.
Do you Subcontract Work?	Yes No Please make a selection.
	If Yes: % or Amt $
Description of Operations A value is required.
Employee Payroll $ A value is required.Invalid format. Gross Sales $ A value is required.Invalid format.
Res. A value is required.Invalid format.The value must be between 0 and 100.The value must be between 0 and 100. % + Comm. A value is required.Invalid format.The value must be between 0 and 100.The value must be between 0 and 100. % + Ind. A value is required.Invalid format.The value must be between 0 and 100.The value must be between 0 and 100. % = 100%
New Construction A value is required.Invalid format.The value must be between 0 and 100.The value must be between 0 and 100. % + Remodel A value is required.Invalid format.The value must be between 0 and 100.The value must be between 0 and 100. % + Repair A value is required.Invalid format.The value must be between 0 and 100.The value must be between 0 and 100. % = 100%
Currently Insured? Yes No Please make a selection - If Yes, Name of Carrier
Prior Claims? Yes No Please make a selection.

GENERAL LIABILITY
Limit Desired:	$1,000,000 $500,000
Do you do Foundation Work?	Yes No
Do you do any Roofing Work?	Yes No
Do you do any work on New Condos or Tract Homes?	Yes No

WORKERS' COMP
Underwriting information:
Payroll Class #1:
List Class Code # if you know it and describe payroll class:	Insert Annual Payroll in dollars for this class here:	$
Payroll Class #2: (if none, leave blank)
List Class Code # if you know it and describe payroll class:	Insert Annual Payroll in dollars for this class here:	$
Payroll Class #3: (if none, leave blank)
List Class Code # if you know it and describe payroll class:	Insert Annual Payroll in dollars for this class here:	$
Payroll Class #4: (if none, leave blank)
List Class Code # if you know it and describe payroll class:	Insert Annual Payroll in dollars for this class here:	$

PROPERTY
Building/office Square footage:
Occupancy:	Owner Tenant
Occupancy Type: (describe entities and number of units, such as "4 unit apartment" or "2 offices and barber shop", etc.)
Number of stories:	One Two Three 4 or More
# of feet to nearest fire hydrant:
# of miles to nearest fire station:

AUTO
VEHICLE COVERAGES:
Limits of Liability		$500,000 CSL $750,000 CSL $1 Million CSL
Comprehensive & Collision		No Coverage $250 Deductible $500 Deductible $1000 Deductible
Uninsured Motorists		Yes No
COMMERCIAL VEHICLE #1: If more than 2 vehicles, list in remarks or call us at: 800-238-4654
Year of vehicle:		Make & Model:
Type (truck, bobtail, etc.):		Cost New: $
Radius of operation:		List Special Equipment & Values (i.e., rack, toolbox, etc.)
VIN# (highly suggested for accurate rating)
COMMERCIAL VEHICLE #2: (If none, leave blank)
Year of vehicle:		Make & Model:
Type (truck, bobtail, etc.):		Cost New: $
Radius of operation:		List Special Equipment & Values (i.e., rack, toolbox, etc.)
VIN# (highly suggested for accurate rating)
DRIVER INFORMATION #1 (If more than two drivers, list in remarks)
Name:		Birthdate:
Number & Type of Accidents within last 3 years	Number & Type of MINOR violations within last 3 years
Number & Type of MAJOR violations within last 3 years	Does Driver need an SR22 FILING?	Yes No
DRIVER INFORMATION #2 (If none, leave blank)
Name:		Birthdate:
Number & Type of Accidents within last 3 years	Number & Type of MINOR violations within last 3 years
Number & Type of MAJOR violations within last 3 years	Does Driver need an SR22 FILING?	Yes No
Remarks

TOOLS
Coverages:
Tool Coverage Amount $	Other Property Amount $
Describe Tools/Property		Deductible $ ($250, $500, $1,000, etc.)
Other Coverage/Remarks (describe any extra coverages needed such as business interruption, robbery, computers, etc.):

UMBRELLA
General Liability Form section must be filled out as well
Limit Desired:	$1,000,000 $2,000,000 $3,000,000 $4,000,000 $5,000,000 +$5,000,000

WRAP

General Liability Form section must be filled out as well

Name of Project
Specific project details

BONDS

License Bond = $12,500
License Bond - Roofer or Swimming Pool = $
Other Bonds (Performance, Bid, Payment, Completion, etc.) -

Currently Bonded? Yes No

Type of Bond Needed
(Be as specific as possible.)

Bond Amount
(List Bond Amount in dollars.) $

Who Requires Bond?
(Who is requiring bond of you - i.e. State,
other third party, or n/a.)

Instant Issue Bonds require credit check. We will call you for further required information.


License #OF41740