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 Employer Identification Number (FEIN):
*
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:
*
example@example.com
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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Do you perform structural work?
*
Yes
No
Does your company perform any roofing operations?
*
Yes
No
Does your company perform any waterproofing?
*
Yes
No
Does your company perform any tract work?
*
Yes
No
Does your company do OCIP (Wrap-up) work?
*
Yes
No
Involved with hazardous waste or materials?
*
Yes
No
Written contract for all work you perform?
*
Yes
No
Work on single family residences > 5,000 SqFt:
*
Yes
No
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
*
Commercial Vehicle Insurance?
*
Yes
No
If Yes, Current Carrier:
*
If Yes, Current Premium:
*
Vehicles:
*
Drivers:
*
Any Additional Information:
Submit
Should be Empty: