| First
Name: |
|
| Last
Name: |
|
| Business
Name: |
|
| Address: |
|
| City: |
|
| State: |
|
| Zip
Code: |
|
| Phone
Number: |
|
| Fax
Number: |
|
| E-Mail
Address: |
|
| Who
Refereed You To Our Site?
|
|
|
Underwriting Information |
|
Number of
Owners: |
|
| Number
of Employees: |
|
| Payroll
of Owners: |
|
| Payroll
of Employees: |
|
| Total
Annual Gross Receipts: |
|
| Total
Annual Sub Costs: |
|
| Current
Insurance Company: |
|
| Select
Your Classification: |
|
| Contractors
License Number: |
|
| License
Type: |
|
| Years
of Experience: |
|
| How
many years have you operated under your current business name: |
|
| Have
you used any other business names during the past 5 years: |
No
Yes
|
| Have
you been involved in the original construction or remodeling
of town homes, condos, row homes or developments of 15 or
more unattached single family dwellings during the past 5
years: |
No
Yes
|
| Do
you construct footings or foundations which may support dwellings
or other structures: |
No
Yes
|
| Do
you construct slab or monolithic floors: |
No
Yes
|
| Do
you construct piers or underpinning which may support dwellings
or other structures: |
No
Yes
|
| Do
you construct retaining walls which may support dwellings
or other structures: |
No
Yes
|
| Do
you construct fireplaces or chimneys: |
No
Yes
|
| Percentage
% of work done as a GENERAL CONTRACTOR: |
|
| Percentage
% of work done as a SUB-CONTRACTOR: |
|
| Percentage
% of work done on RESIDENTIAL: |
|
| Percentage
% of work done on COMMERCIAL: |
|
| Percentage
% of work done for REMODELING: |
|
| Percentage
% of work done for RENOVATION: |
|
| Percentage
% of work done for REPAIR - MAINTANENCE: |
|
| Losses-Claims
in the last 5 years: |
|
| If
yes, Date, Amount Paid & Description of each Loss-Claim |
|
| Liability
Limits Requested: |
|
|
|
