CALL 844-967-5247 (844-WORK-247) FOR A QUICK QUOTE.

General Liability Workers' Compensation Commercial Auto Builders Risk Contractor Bonds Cyber Liability Professional Liability Niche Trades Life Insurance

Blog FAQ Map Forms Coverage Areas

Safety Program Policy Review Checklist Claim Management Checklist

Informational Videos Profit and Loss Audit Builders Risk Application Homeowners Application Work Comp Forms Arizona Contractor Insurance

About CCA Josh Cotner, Founder

Contact Us Get a Quote Report a Claim

Our Locations

All Locations Sun Lakes Arizona Office Downtown Phoenix Arizona Office Miami Florida Office

CERTIFICATES GET QUOTE

INSURANCE PROGRAMS

General Liability Workers' Compensation Commercial Auto Builders Risk Contractor Bonds Cyber Liability Professional Liability Niche Trades Life Insurance

RESOURCES

Blog FAQ Map Forms Coverage Areas Safety Program Policy Review Checklist Claim Management Checklist Informational Videos Profit and Loss Audit Builders Risk Application Homeowners Application Work Comp Forms Arizona Contractor Insurance

ABOUT

About CCA Josh Cotner, Founder

CONTACT Get a Quote Report a Claim

Our Locations

All Locations Sun Lakes Arizona Office Downtown Phoenix Arizona Office Miami Florida Office

View Insurance Certificates

Loading...

Loading...

Loading...

Loading...

Loading...

Loading...

Loading...

Loading

Loading page...

Contractor's Choice Agency

America's Trusted Contractor Insurance Specialists

Founded by Josh Cotner in 2005 • 20+ Years Experience • National Producer Number 8608479

Click For Certificates

Contact Us

Primary

Secondary

855.336.7189

Speak directly with our founder:

Josh Cotner - Available 24/7

Open 24 Hours

All Days

Our Offices

Sunlake Insurance Arizona

12220 E Riggs Rd
Chandler, AZ 85249

Phoenix Insurance Arizona

4435 E Chandler BLVD Suite 200
Phoenix, AZ 85048

Our Services

General Liability Insurance
Workers' Compensation
Commercial Auto Insurance
Builders Risk Insurance
Contractor Bonds
Get a Quote

Quick Links

About Us
Josh Cotner, Founder
Arizona Contractors
Insurance Blog
Contact Us
Coverage Areas
State Insurance Guides
Interactive State Map

National Producer Number: 8608479

Licensed in: 50 States

Established: 2005

Terms of Use|Privacy Policy

© 2026 Contractor's Choice Agency. All rights reserved.

Professional Contractor Insurance Specialists • Serving America's Builders Since 2005

josh@contractorschoiceagency.com

Don't fill this out if you're human:Name: Email: Phone: Service:Message:

Don't fill this out if you're human:Name: Email: Phone: Service:Preferred Contact:Best Time to Contact:Message:

ACORD 125 — Commercial Insurance Application

Applicant, premises, prior carriers and loss history — the common section every commercial submission starts with.

349 questions, grouped by the page they appear on in the printed ACORD form.

Fill in what applies to you and leave the rest blank — we will follow up on anything we still need. Other sections: 125 · 126 · 140

Loading application...

Don't fill this out if you're human:

1. Business Phone #:

Current

NAIC Code

Carrier Name

Program Name

Program Code

Agency Name

Policy Number

Producer Contact

Underwriter

Underwriter Office

Producer Phone Number

Producer Fax Number

Quote TransactionYes

Issue Policy TransactionYes

Renew TransactionYes

Bound TransactionYes

Producer Email Address

Change TransactionYes

Transaction Time is AMYes

Producer Code

Producer Subcode

Transaction Date

Transaction Time

Cancel TransactionYes

Transaction Time is PMYes

Agency Customer ID

Business Auto Premium

Business AutoYes

Amount of Deposit

Minimum Premium

Policy Premium

Policy Effective Date

Payment Plan

Method of Payment

Audit

Policy Expiration Date

Direct Billing PlanYes

Agency Billing PlanYes

GL Code

Named Insured SIC

Named Insured NAICS

Named Insured FEIN or SSN #

Named Insured

Named Insured Phone Number

Named Insured Website

Named Insured Mailing Address

CorporationYes

Joint VentureYes

Not For ProfitYes

Subchapter S CorporationYes

Number of Members

IndividualYes

LLCYes

PartnershipYes

TrustYes

Second Insured GL Code

Second Insured SIC

Second Insured NAICS

Second Insured FEIN or SSN #

Second Insured Name

Second Insured Phone Number

Second Insured Mailing Address

Second Insured Website

CorporationYes

Joint VentureYes

Not For ProfitYes

Subchapter S CorporationYes

Number of Members

IndividualYes

LLCYes

PartnershipYes

TrustYes

Third Insured SIC

Third Insured NAICS

Third Insured FEIN or SSN #

Third Insured GL Code

Third Insured Name

Third Insured Phone Number

Third Insured Website

Third Insured Mailing Address

CorporationYes

Joint VentureYes

Not For ProfitYes

Subchapter S CorporationYes

Number of Members

IndividualYes

LLCYes

PartnershipYes

TrustYes

2. E-Mail Address:Reason For Interest:

Contact Type

Contact Type

Contact Name

Contact Name

Home PhoneYes

Business PhoneYes

Cell PhoneYes

Home PhoneYes

Business PhoneYes

Cell PhoneYes

Home PhoneYes

Business PhoneYes

Cell PhoneYes

Home PhoneYes

Business PhoneYes

Cell PhoneYes

Primary Phone Number

Secondary Phone Number

Primary Email Address

Primary Email Address

Secondary Email Address

Secondary Email Address

Annual Revenue

Location Number

Full Time Employees

Street

Occupied Area in Square Feet

Inside City LimitsYes

Interest is OwnerYes

Area Open to Public in Square Feet

City

State

Outside City LimitsYes

Interest is TenantYes

Part Time Employees

Building Number

Total Building Area in Square Feet

County

ZIP

Is Building Leased to Others?

Description of Operations

Annual Revenue

Location Number

Full Time Employees

Street

Occupied Area in Square Feet

Inside City LimitsYes

Interest is OwnerYes

Area Open to Public in Square Feet

City

State

Outside City LimitsYes

Interest is TenantYes

Part Time Employees

Building Number

Total Building Area in Square Feet

County

ZIP

Is Building Leased to Others?

Description of Operations

Annual Revenue

Location Number

Full Time Employees

Street

Occupied Area in Square Feet

Inside City LimitsYes

Interest is OwnerYes

Area Open to Public in Square Feet

City

State

Outside City LimitsYes

Interest is TenantYes

Part Time Employees

Building Number

Total Building Area in Square Feet

County

ZIP

Is Building Leased to Others?

Description of Operations

Annual Revenue

Location Number

Full Time Employees

Street

Occupied Area in Square Feet

Inside City LimitsYes

Interest is OwnerYes

Area Open to Public in Square Feet

City

State

Outside City LimitsYes

Interest is TenantYes

Part Time Employees

Building Number

Total Building Area in Square Feet

County

ZIP

Is Building Leased to Others?

Description of Operations

ApartmentsYes

ContractorYes

ManufacturingYes

RestaurantYes

ServiceYes

Date Business Started

CondominiumsYes

InstitutionalYes

OfficeYes

RetailYes

WholesaleYes

Description of Primary Operations

Retail Stores or Service Operations % of Total Sales

Installation, Service or Repair Work %

Off Premises Installation, Service or Repair Work %

Description of Operations of Other Named Insureds

CertificateYes

PolicyYes

Send BillYes

LienholderYes

Additional InsuredYes

Loss PayeeYes

Additional Interest Name and Address

Co-OwnerYes

Employee as LessorYes

OwnerYes

LeasebackYes

RegistrantYes

Reference or Loan #

Interest End Date

Lien Amount

Phone Number

Fax Number

Other Description

OtherYes

Reason for Interest

Email Address

3. Effective Date

Is Applicant a Subsidiary?Yes

Ownership Percentage

Parent Company Name

Relationship Description

Does Applicant Have Subsidaries?Yes

Ownership Percentage

Subsidary Company Name

Relationship Description

Safety Programs Exist?Yes

Other Text

Safety ManualYes

Safety PositionYes

Monthly MeetingsYes

OSHAYes

OtherYes

Any Exposure to Flammables, Explosives, Chemicals?Yes

Exposure Description

Any other Insurance wth this Company?Yes

Line of Business

Policy Number

Line of Business

Policy Number

Line of Business

Policy Number

Line of Business

Policy Number

Policy Coverage Terminated?Yes

Non-PaymentYes

Agent No Longer Represents CarrierYes

Coverage Corrected Description

Non-RenewalYes

UnderwritingYes

Condition CorrectedYes

Past Allegations of Abuse, Molestation, or Discrimation?Yes

Past Allegations Description

Any Indictments or Convictions?Yes

Indicted or Convicted Description

Any Uncorrected Fire and/or Safety Violations?Yes

Occurence Date

Resolution

Resolution Date

Explanation

Occurence Date

Resolution

Resolution Date

Explanation

Any past negative financial action?Yes

Occurence Date

Explanation

Resolution

Resolution Date

Occurence Date

Explanation

Resolution

Resolution Date

Any Judgement or Lien?Yes

Occurence Date

Explanation

Resolution

Resolution Date

Occurence Date

Explanation

Resolution

Resolution Date

Trust Name

Has Business been placed in a Trust?Yes

Any Foreign Operations or Products?Yes

Do other Ventures exist?Yes

Description of Other Ventures

Does Applicant Possess Drones?Yes

Description of Drone Possession

Does Applicant Hire Drone Operators?Yes

Description of Drone Hiring

General Remarks

Prior Auto Carrier

Prior Auto Policy Number

Prior Auto Premium

Prior Auto Year

Prior Auto Effective Date

Prior Carrier Auto Expiration Date

4. Signature

Prior Auto Carrier

Prior Auto Policy Number

Prior Auto Premium

Prior Auto Year

Prior Auto Effective Date

Prior Auto Expiration Date

Prior Auto Carrier

Prior Auto Policy Number

Prior Auto Premium

Prior Auto Year

Prior Auto Effective Date

Prior Auto Expiration Date

No Prior Loss HistoryYes

Total Cost of Prior Losses

Requested # of Years

Occurence Date

Line of Business

Description

Date of Claim

Amount Paid

Amount Reserved

Subrogation Exists?

Claim Open?

Occurence Date

Description

Date of Claim

Amount Paid

Amount Reserved

Subrogation Exists?

Claim Open?

Line of Business

Occurence Date

Description

Date of Claim

Amount Paid

Amount Reserved

Subrogation Exists?

Claim Open?

Applicant Initials

Producers Signature

Producers Name

Producers License Number

Applicants Signature

Applicant Date

National Producer Number