PEI Quote Form

General Liability & Pollution Liability Application

Company Name:		*Sponsored Insurance Program*
Renewal Date:
Contact:
Street Address:
City:
State:
Zip Code:
Email Address:
Phone:
Fax:

Gross Field Payroll Information:

Expected Gross Payroll: (do not include clerical or executive officers)	$
Number of Executive Officers in the Field:	#

Please estimate the amount of payroll for the given Class Code:

Code: 97223	Machinery & Equipment Service, Installation or Repair (Ex: Installations, Removals, Decommissioning of tanks)	Payroll	$
Code: 97223		# of Employees	#
Code: 97223	Computer Service Techs (employees that work strictly with computer components of dispensers and POS systems, etc.)	Payroll	$
Code: 97223		# of Employees	#
Code: 94007	Excavation (Actual Time on Backhoe)	Payroll	$
Code: 94007	Excavation (Actual Time on Backhoe)	# of Employees	#
Code: 15062	Machinery & Equipment Dealers (This is based on retail sales to third parties ONLY; Sales involving your own jobs/work are NOT INCLUDED)	Retail Sales	$
Code: 92102	Environmental Drilling ( Environmental Test Holes, Core Samples)	Payroll	$
Code: 92102		# of Employees	#
Code: 91135	Analytical Chemist (Tank Testing, Consulting, etc.)	Payroll	$
Code: 91135	Analytical Chemist (Tank Testing, Consulting, etc.)	# of Employees	#
Code: 91581	Independent Contractors (This is based on total cost of jobs)	Total Cost of Subcontractors	$

Gross Sales Information:

Please estimate the percentage of Gross Sales per the following class codes for the upcoming policy year:

Installation/Removal of UST's	%
Petroleum Equipment Sales to Third Parties	%
Environmental Consulting	%
Cathodic Protection	%
Tank/Soil Testing	%
	%
	%
	%
	%

Current Information:

General Liability Insurance Carrier
Pollution Coverage Insurance Carrier
Professional Coverage Insurance Carrier
If Claims Made, Retro Date	,

Please indicate which coverages you would also like quoted:

Please describe ALL General Liability, Pollution Liability, and Professional Liability Claims in the last 3 years:

If the form does not work properly, please print this form and fax it to 817.640.0131

...Or if you have already completed an application for another agent please fax that to us as it may have same information we require.