PBIA Digital Forms

Contact Information

Business Name *

Contact Name *

Phone Number *

Email Address *

California Contractor License Number

Street Address *

City *

State *

ZIP Code *

Type of Contractor / Work Performed *

Years in Business

Requested Effective Date

Types of Work

Business Operations

Detailed Description of Work Performed *

Estimated Annual Gross Sales *

Estimated Annual Payroll *

Number of Employees *

Percentage of Work Subcontracted *

Largest Project Completed *

Largest Project Planned During the Next 12 Months *

Maximum Work Height (feet)

Maximum Excavation Depth (feet)

Work Territory *

California onlyMultiple statesOther

Coverage Requested

Underlying Insurance

Is your General Liability policy currently written through our agency? *

YesNo

Do you have a Commercial Auto policy? *

YesNo

Do you have employees requiring Workers’ Compensation coverage? *

YesNo

Do you need any other policy included beneath the Excess Liability coverage? *

YesNo

Additional Coverage

Should any other policy be included under the Excess Liability coverage?

Claims and Loss History

Have you had any General Liability, Commercial Auto, Employers Liability, or other relevant claims during the past five years? *

YesNo

Current Excess Coverage

Do you currently have an Excess Liability or Commercial Umbrella policy? *

YesNo

Supporting Documents

Upload these documents if available.

Current Excess or Umbrella policy

Optional: PDF, Word, Excel, JPG, or PNG. All uploads combined: 3 MB maximum.

Five years of loss runs

Optional: PDF, Word, Excel, JPG, or PNG. All uploads combined: 3 MB maximum.

Contract showing the required insurance limits

Optional: PDF, Word, Excel, JPG, or PNG. All uploads combined: 3 MB maximum.

Commercial Excess Liability Quote Request

Contact Information

Types of Work

Business Operations

Coverage Requested

Underlying Insurance

Additional Coverage

Claims and Loss History

Current Excess Coverage

Supporting Documents

Additional Information