Contractor General Liability Insurance
Referring Agent
First Name
Last Name
Referring Agent's Phone Number
-
Area Code
Phone Number
Referring Agent's Email
example@example.com
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Federal Employee Identification Number
Entity Type
Business Legal Name
*
Type Individual Name if Entity is Individual
DBA
Street Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Email
*
Website
Years in Business
Exp. in Field
States You do Business
Contractor's License #
Percentage of Operations: GC
Percentage of Operations: Sub
Percentage of Operations: Owner/Builder
Direct Payroll
Subcontractor Cost
Number of Field Employees
Number of Owners
Type of Work Performed (in percentages)
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1) Do you perform structural work?
*
Yes
No
2) Does your company perform any roofing operations?
Yes
No
3) Does your company perform any waterproofing?
Yes
No
4) Does your company perform any tract work?
Yes
No
5) Does your company do OCIP (Wrap-up) work?
Yes
No
6) Involved with hazardous waste or materials?
Yes
No
7) Written contract for all work you perform?
*
Yes
No
8) Work on single family residences > 5,000 SqFt.
Yes
No
9) Any licensing authority take action against you?
*
Yes
No
Do you use subcontractors? If so, do you collect certificates? Require they have insurance limits equal to your own? Require subcontractors to name you as additional insured? Standard formal written contract in place? Hold harmless/indemnification in your favor? Require subcontractors to carry Worker’s Compensation?
*
Max Height Work Performed
Max Below Grade
# of Projects Started
# of Projects Completed
Describe the largest project, including total cost, which you have performed in the last 5 years?
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Name of Safety Director
*
First Name
Last Name
Formal Written Safety Program?
*
Yes
No
Any Losses in the Last 5 years?
*
Yes
No
Loss Runs
Yes
No
Complete Description of Operations
*
Current Carrier for Liability
Current / Renewal Premium
Current Carrier for Worker's Comp
Current / Renewal Premium
Liability Amount
500k/1mil
1mil/2mil
2mil/4mil
Deductible
500
1,000
1,500
2,000
2,500
Business / Personal Property Contents Amount
Inland-Marine Coverage?
Yes
No
Scheduled Equipment
1
2
3
4
5
Commercial Vehicle Insurance?
Yes
No
If Yes, Current Carrier
If Yes, Current Premium
Vehicles
Drivers
Any Additional Information
Submit
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