Contractor's Quote Form

                             Email Address:     

 

First Name         Current Address

  Last 
  Daytime Phone DOB SSN #
  Current Company  Expires   Premium $
 

City

 Type of Work  

 

Years in Business

 # of Employees # of Owners

 

Current Coverage

 

Est. Emp. Annual Payroll

 

Coverage Needed:

Property          Liability          Workers Comp          Builders Risk

Auto (additional info required)

                                                                                                   

Disclaimer:  It is our intent to release quote information only to you and we have taken every step to keep your information private.  "Fallon Insurance Agency , Inc." does not accept  any responsibility for information accidentally viewed by others via the Internet.  Quotes are outlines of available coverage and are not binding in any legal manner.  All quotes are subject to the terms, conditions, provisions, limitations and exclusions of the actual policy issued between the insurance company and yourself.