Contractor Name
Contractor Main Address/Location
Contractor Phone
Format: (000) 000-0000.
Contractor Website
CEO Name
CEO Email
CEO Cell
Format: (000) 000-0000.
CFO Name
CFO Email
CFO Cell
Format: (000) 000-0000.
COO Name
COO Email
COO Cell
Format: (000) 000-0000.
Safety Name
Safety Email
Safety Cell
Format: (000) 000-0000.
Name of individual filling out the form
First Name
Last Name
Email of individual Filling OUT the Form
example@example.com
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Next Step
Agent/Broker Name
Broker Cell
Format: (000) 000-0000.
Broker Email
Incumbent Broker Status
Please Select
Incumbent Broker
Not Incumbent Broker
Current Policy Expiration Date
-
Month
-
Day
Year
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Next Step
What industry group(s) best describes you?
Heavy Civil
Industrial
General Building
Are you privately owned?
Please Select
Yes
No
Any ownership by private equity
Please Select
Yes
No
Any foreign ownership?
Please Select
Yes
No
States of operation and percentages (generally)
Estimated Annual Receipts
Percentage of Subcontracted Work
Estimated Annual WC Payroll
Estimated Annual Workforce Hours
Net Worth
estimated premiums (workers comp, auto liability, and general liability) before deductibles (e.g., first-dollar)
Company History/Story
Were you referred by a member? Who?
Existing Member Connections
How did you find out about ACIG?
Union
Non-Union
Double-Breasted
Person completing this form
First Name
Last Name
Submit Initial Contact Form
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