Mortgage Field Services Insurance Application Form One Simple Form - takes only 2-3 Minutes! FOR FAST QUOTES - Answer ALL QUESTIONS! If you answer a question "YES" and there is a follow-up question, you MUST complete the follow up question! Be specific about Job/Work performance Minimum Premium for First Mercury Safeguard Program is $1,000.00 Plus Fees - Please Keep this in Mind. NOT FOLLOWING THESE INSTRUCTIONS WILL ONLY DELAY YOUR QUOTE FOR 72 HOURS OR LONGER
Your Name:
BUSINESS Name:
Mailing Address:
City:
State:
Zip/Postal:
Company Web Site Address:
E-Mail (REQUIRED):
Phone:
Fax (optional):
Business Underwriting Information
State(s) of operation:
Years in Business:
Effective Date of Coverage Requested:
Claims Made Retro Date:
Is similar Professional Liability (Errors & Omissions) currently in force?	Yes No
a) if yes, provide copy of      declaration page      b) If yes, please provide Carrier’s name,      current limits, expiration date:
Is similar General Liability currently in force?	Yes No
a) if yes, provide copy of      declaration page      b) If yes, please provide Carrier’s name,      current limits, expiration date:
Projected Annual Gross Receipts:	$
Projected Annual Costs for Third Party Subcontractors:	$
Projected Annual Gross Payroll:	$
(Please Note: ONLY fill in the fields in the table below where there is a monetary amount to put in. If there is nothing, leave the cell blank.) Payroll/Sales Description |    Payroll   | Sales Glass Dealers and Glaziers [13590] Locksmiths [14913] Pest Control Services [43470] Real Estate Property Managed [47052] Carpentry - 3 Stories or Less [91340] Drywall or Wallboard Installation [92338] Engineers or Architects [92663] Inspection or Appraisal Company [96317] Janitorial Services [96816] Lawn Care Services [97050] Plumbing, Residential [98483] Roofing, Residential [98678] Snow & Ice Removal [99310] Truckers / Movers [99793] Other (Detail in Remarks) Other (Detail in Remarks) Other (Detail in Remarks)
Provide a detailed description of your operations. Give us as much information as you can:
1. How Long Have You Been a Safeguard Contractor?
2. Are You a Licensed Contractor?	Yes No
3. Is there a Formal Safety Program in Place?	Yes No
If so, please describe it or provide documentation, such as as a safety manual:
4. Are you in compliance with Safeguard's Program Requirements?	Yes No
5. Do you perform work outside the Safeguard Program?	Yes No
If so, and you currently have     General Liability coverage, please     identify the insurance carrier,     policy term and limits:
6. Have you Ever Had your General Liability or Professional Liability insurance cancelled or non-renewed?	Yes No
If so, please describe when      and why it was cancelled:
7. Have you experienced a LOSS greater than $10K in the past 5 years?	Yes No
If so, please describe each claim and provide details including claimant, date of loss, status (open/closed), paid loss/expense, and reserved loss/expense.
8. Have you experienced 3 or more CLAIMS in any one year over the past 5 years?	Yes No
If so, please describe each claim and provide details including claimant, date of loss, status (open/closed), paid loss/expense, and reserved loss/expense.
9. Have you ever had a construction defect claim?	Yes No
If so, please describe each claim and provide details including claimant, date of claim, status (open/closed), paid loss/expense, and reserved loss/expense.
10. Do you ever use sub-contractors?	Yes No
If so, do you require ALL of the following from your subcontractors: carry insurance with limits equal to or greater than your own, name you as an Additional Insured with a favorable Hold Harmless agreement, and provide you with a Certificate of Insurance?	Yes No
If you use sub-contractors, please describe the type(s) of work and the % of your total gross receipts that is subcontracted.
11. Have your gross receipts or payroll grown by over 20% in the past 3 years?	Yes No
If so, and your gross receipts are more than $75,000, please provide your total gross receipts and payroll for each of the past 3 years.
12. Do you ever work on properties that have more than 3 stories?	Yes No
If so, please describe the type(s) of work performed and the % of your total gross receipts involving jobs with properties that have more than 3 stories:
13. Are you ever involved in new construction?	Yes No
If so, please describe how you are involved and the % of your total gross receipts involving jobs with new construction:
14. Do you ever perform any environmental remediation (including, but not limited to, work involving mold, asbestos, or lead)?	Yes No
If so, please describe the work performed and the % of your total gross receipts involving jobs that include environmental remediation:
15. Do you ever handle hazardous waste?	Yes No
If so, please describe the type(s) of hazardous waste, why you handle it, and the % of your total gross receipts involving jobs that include hazardous waste:
16. Do you ever preserve properties that are valued at more than $2,000,000?	Yes No
If so, what % of your total gross receipts involve properties valued at more than $2,000,000?
17. Please describe 3 jobs on which you are currently working. For each, please provide the client/location, a description of what you have been contracted to do for the client, and the gross receipts that you will be paid. If you do not have 3 current jobs, please provide this information for the last three jobs that you completed:
18. Do you perform demolition work?	Yes No
If so, please describe the type(s) of structures you demolish and the % of your total gross receipts involving jobs that include demolition work:
19. Do you ever work with roofs?	Yes No
If so, please describe the type of work and the % of your total gross receipts involving jobs that include roof work:
20. What % of your work involves residential properties and what % is commercial?
21. Do you repair properties?	Yes No
If so, please describe the type of repair (carpentry, electrical, plumbing, other) and the % of your total gross receipts involving jobs that include repair work
22. Do you have any discontinued operations or exposures that have not already been described in this application?
23. Do any of your clients require their name listed as an additional insured?	Yes No
If yes, please list the name,      address & business relationship of      any requested Additional Insured
Projected Annual Gross Receipts:	$

Thank you for filling out this form COMPLETELY! We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release them from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy. Yes, I Agree. Please Send Me a Quote NOW!

Click Button Below When Done Please Click Only Once . . . May take up to 30 seconds!