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Home » Our Forms » Contractor Information Application

Everyone’s insurance needs are different. Consider filling out our form and we’ll get back to you soon.

Get the contractor insurance coverage for your needs.

Please complete the form to your best ability. Fields marked with an * are required.

"*" indicates required fields

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General Information

Name/DBA/Company Name (as your name appears on the contract*

Owner Name*

First Name* Last Name*

Is the owner involved in day to day operation?*

Yes

Date of Birth*

Address*

Street Address* City* State* ZIP Code*

Phone Number*

Contractor Information

Do you need any Federal Filings?

Yes

Cargo Filings?

Yes

DOT#

MC#

In what states will you be delivering?*

Will you be working as a “travel team” and operating in any states outside of your base state?

Yes

Are you involved in any other operations NOT related to appliance/furniture installation?

Yes

Untitled

If yes, please explain.

How many years of current continuous experience in appliance/furniture installation operations?*

Are there any losses in the last 5 years? Please list.

Vehicle Information

Number of Vehicles*

Add year, make/model, and VIN for up to five vehichles.

Vehicle 1 Year

Vehicle 1 Makel/Model

Vehicle 1 VIN

Vehicle 2 Year

Vehicle 2 Make/Model

Vehicle 2 VIN

Vehicle 3 Year

Vehicle 3 Make/Model

Vehicle 3 VIN

Vehicle 4 Year

Vehicle 4 Make/Model

Vehicle 4 VIN

Vehicle 5 Year

Vehicle 5 Make/Model

Vehicle 5 VIN

Driver Information

Number of Drivers*

Add driver information for up to five drivers.

Driver 1 Name

Driver 1 Date of Birth

Driver 1 Drivers License

Driver 1 State

Any tickets or claims in the past 5 years for Driver 1?*

Yes

Driver 2 Name

Driver 2 Date of Birth

Driver 2 Drivers License

Driver 2 State

Any tickets or claims in the past 5 years for Driver 2?*

Yes

Driver 3 Name

Driver 3 Date of Birth

Driver 3 Drivers License

Driver 3 State

Any tickets or claims in the past 5 years for Driver 3?*

Yes

Driver 4 Name

Driver 4 Date of Birth

Driver 4 Drivers License

Driver 4 State

Any tickets or claims in the past 5 years for Driver 4?*

Yes

Driver 5 Name

Driver 5 Date of Birth

Driver 5 Drivers License

Driver 5 State

Any tickets or claims in the past 5 years for Driver 5?*

Yes

Additional Information

Are there any losses in the last 5 years? Please list.

Product Being Installed

Furniture

Appliance

Both

Other

Parking Address*

Parking State*

Parking ZIP*

Payroll Information

What company do you have a contract with?*

What store are you delivering for?*

Weekly payroll for driver?*

Weekly payroll for helper?

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Maury Donnelly & Parr, Inc. is a professional insurance agency that is devoted to keeping our insured protected and providing them with insurance solutions for their needs. MDP strives to offer personalized levels of service in our niche programs as well as a wide range of insurance knowledge to write most classes of business, regardless of their size. Our goal is to provide insurance of the highest quality so every client may obtain coverage levels that are right for their unique situation and to always value coverage over policy price.

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