NEWS Insurance Services Inc.

Contractors

1501 Westcliff Dr. Suite 301
Newport Beach, CA. 92660
Tel: (877) 700- NEWS
Fax: (949) 554-0250
Email: quote@newsinsurance.com
Web: www.newsinsurance.com

PERSONAL INFORMATION

* Mandatory fields

Quote Date :
First Name :	*
Last Name :	*
Mailing Address :	*
City :	State : Zip Code : *
Home No. :	*
Cell No. :	*
Business No. :
E-Mail. :	*
Current Policy Expiration Date :
Social Security No. :
Location of Garage : (if diff. from Above)
City :	State : Zip Code :
Choose from the Following:

Complete Supplemental Questionnaire

Is this questionnaire for :	New Business? Renewal Business?
If “renewal” give current policy number :

INSURED

When did the applicant's business start?
How long has the applicant been in this line of work? :
Is or has the applicant ever been involved in any other business venture as an owner or officer?	if Yes
explain:
. Has this business or any other business in which the insured is or was involved as an owner or officer ever declared bankruptcy?	if Yes
explain:
What classes of contractors licenses does the applicant hold?
License number(s) :

EMPLOYEES

Provide the following information concerning employees for the past three years and give an estimate for the next 12 months:

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Number of Full-time Employees	Number of Part-time Employees

PAYROLL AND RECEIPTS

Provide the following information for the past three years (use audited information if possible) and give an estimate for the next 12

Year	Total Receipts	Payroll (excluding partners and officers)
	$	$
	$	$
	$	$
Estimate	$	$
Commercial : %
New Repair or Remodelling New Residential New commercial
Residential : %
New Repair or Remodelling New Residential New commercial
Industrial : %
New Repair or Remodelling New Residential New commercial