Contractor Questionnaire
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Company
*
For Internal Proposes only
I am ready to take FORDNS
What type of entity are you?
*
LLC
INC
Sole proprietorship
Do you have a " Doing Business As" Name
Yes
No
Doing business as name
*
First Name
*
Last Name
*
mobile
Please enter a valid phone number
Federal ID Number or equivalent if a sole proprietor.
*
What is your Date of Birth?
/
Month
/
Day
Year
Date
Address Mailing
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is your mailing address the same as your physical address?
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Yes
No
Physical Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
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example@example.com
How many years have you been in business?
*
For Internal use only Comment box FORDNS AND To Do list
List the states you do business in
*
17. Indicate the anticipated construction work over the next 12 months to be performed by you and your Employees. Check all that apply
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HVAC
Electrical
Insullation
Plumbing
Roofing
Pool
Excavation
Grading
Debris Cleanup
landscaping
Masonry
Painting
Carpentry
Tile
Flooring
Remodeling
Pressure Washing
Do you perform Soft wash Roof cleaning
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Yes
No
Does your pressure washer go above 4000 PSIs?
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Yes
No
How many stories do you go up to?
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If Applicable: Contractor License Number
*
Give the percentage breakdown of commercial vs residential construction work that you perform
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What are your projected gross sales per year
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Have you been involved in or are you aware of pending litigation concerning defective workmanship?
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No
Yes
Please Select
Do any of your operations involve:-Asbestos removal-Pile driving, shoring or underpinning? -Blasting-Demolition-Railroad easement-Synthetic stucco-Work above 3 stories-Mold remediation-Controlled burns-Underground work-Movement of any load bearing walls?
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No
Yes
Please Select
Explain any work that was answered yes from above ( If applicable)
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Are you involved in any other business besides contracting?
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No
Yes
Please Select
How many employees do you have?
*
What is your projected payroll (excluding owners) for the upcoming year
*
Do you hire subcontractors?
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Yes
No
Please Select
What is your projected subcontractor cost for the year?
*
Do you require all subcontractors to carrier general liability insurance that is equal to your limits?
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Yes
No
In would like a quote on the following lines of business to protect my company ( CHECK ALL THAT APPLY)
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General Liability: Coverage that can protect you from a variety of claims including bodily injury, property damage, personal injury to others
Workers Comp: Covers medical expenses and 66% lost wages for employees who get injured or ill on the job. HAVE 1 EMPLOYEE? YOU ARE MANDATED TO HAVE IT
Inland Marine: Coverage for your equipment that moves with you.
Commerical Auto
Do you have a vendor that is requiring insurance?
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Yes - I understand before my agent will quote coverage, they will need a copy of the vendor packet to amke sure all requierments are met.
No
Would you like a quote for your homeowners Insurance for a potential discount?
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Yes
No
How Did you hear about us?
*
Google
Referral from a friend
Sign on Building
Facebook/Giveaway
I know agent personally
FOR INTERNAL NOTES ONLY: Does this qualify for a BOP?
Yes
No
What is your home address?
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I opt in to receive text and email *
*
Yes
No
Submit
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