PBIA Digital Forms

Section 1 of 4

Business Profile

Tell us how to get in touch and which business entity this request represents.

Lookup Business (CSLB)

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Business Name *

License / Application Fee #

Business Street *

Business City *

Business State *

Business Zip *

FEIN #

Date Business Started *

Phone Number *

Email *

Business Website (if none, enter NA) *

Mailing / Home Address

Mailing address is the same as business

Section 2 of 4

Ownership & Experience

Share key experience details so we can align the right markets to your account.

Number of Owners *

Years of Experience *

Years in Business *

Owner 1First name, last name, title, SSN, ownership

First Name

Last Name

Position / Title

SSN/ITIN (9 digits)

Ownership %

Active (On The Field)

YESNO

Full Detailed Description of Operations (at least 10 words) *

Section 3 of 4

Exposure & Financial Snapshot

Help us understand the scope of work, subcontracting practices, and payroll mix.

Do you use subcontractors?

YESNO

Financial Snapshot

Enter annual estimates for the upcoming 12-month policy period. All amounts must cover the same 12 months. Do not enter monthly amounts.

Estimated Annual Gross Receipts (Total Revenue) *

Annual total

Enter the total sales or revenue expected from all work during the next 12 months, before subtracting employee payroll, subcontractor costs, materials, taxes, or other business expenses. Do not enter profit or monthly revenue.

Estimated Annual W-2 Employee Payroll *

Annual total

Enter the total gross wages expected to be paid to W-2 employees during the next 12 months. Do not include payments made to 1099 subcontractors.

Number of W-2 Field Employees *

Enter the number of W-2 employees who perform work in the field. Do not include owners, office employees, or subcontractors.

Optional Supporting Documents

Upload any available subcontractor Certificates of Insurance, payroll reports, project schedules, or other documents that support the information entered above.

Section 4 of 4

Projects & Mix

Tell us where you build today and what’s in the pipeline over the next year.

% Commercial *

% Residential *

% New Construction *

% Remodeling *

Largest Job in Last 3 Years (Dollar Amount) *

Largest Current or Planned Job (Next 12 Months) *

Do you currently have an active policy?

YESNO

Upload Documents

All required fields are marked with *