Florida Landscaper and Contractor's Insurance Quote - low cost coverage and high priced service!

Vista Healthplan, Inc.

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© 2004 J.A. MESSINA INSURANCE
PO Box 244571
Boynton Beach, FL 33424-4571
Phone: 561-736-2162
Fax: 561-736-0228
License#A177282
E-Mail us at:
jamessinains@comcast.net

For Your Convenience,
We gladly accept:

"All Our Policies Come With
an Agent!"

Need Coverage TODAY? After Submitting
Your Quote Form (see below), Call Toll-Free:
1-800-735-2162
(Monday-Friday 9:00am-5:00pm Florida local time)

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

Your Name:

BUSINESS Name:

Mailing Address:

City:

State: (Must be Florida)

Zip/Postal:

E-Mail (REQUIRED):

Phone:

Fax (optional):

Business Underwriting Information

Type of operation:

Describe operations in detail:

License class:

License Number:

Social Sec. or Employer ID#:

Limit of Liability
Coverage Requested? $300,000
$500,000
$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
(Supervisory):

Number of Active Owners
(In Field):

Number of Full Time Employees:

Number of Part Time Employees:

Annual Employee Payroll: $

Annual Gross Sales: $

(for Landscapers only)

Lawn Cutting, Trimming Receipts: $

Lawn Cutting, Trimming Payroll: $

Landscaping Construction Receipts: $

Landscaping Construction Payroll: $

Landscaping Subcontracting Receipts if any: $

List any professional landscape or arborist association you are a member of:

Describe any pesticides or herbicides you use in your operations:

Do you own, use, lease or borrow cranes? Yes No

Other Contractor Underwriting Questions

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

Comments/Remarks:

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