Web Designer Client Questionnaire

Contractor Application
Applicant Information
Business Name
Entity of Company
Main Contact

First NameLast Name
Title
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
E-mail
Current Website URL (if applicable)
FEIN or SSN
Estimated Total Gross Receipts
Estimated Subcontracting Costs
# of Field Employees
Annual Payroll
Years in Buiness
Years experience
Is this a premise only policy?

YesNo
# Losses in last 5 years
Estimated Material Costs
Desired Effective Date
States in which you do business for which you are currently applying for insurance:
Description of Operations:
Complete Description of Operations:
Type of Work Performed
Residential %
Commercial %
New%
Remodel/Service Repair%
Percentage of Tract Work: Size if Tract Work:

Contractor Application