Contractor Interest Form
Complete this form if you are a contractor who is interested in providing services to recipients of the Illinois Home Modification Program. https://incil.org/homemod/
Business Name
Type of Business
Sole Proprietor
Partnership
Corporation
LLC
Other
Contractor Name
*
First Name
Last Name
Title
Email
example@example.com
Business Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have multiple owners or partners?
Yes
No
If registered with the State of Illinois, can you provide a certificate of good standing?
Yes
No
Unsure
My business is not a registered entity with the State of Illinois.
Can you provide business and work references?
Yes
No
Unsure
Are you able to provide proof of the following?
Worker's Compensation and Employee's Liability
Auto Insurance
Comprehensive Public Liability
If you use subcontractors, proof of subcontractor insurance.
Please verify that you are one person
*
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Submit
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