Contractor Questionnaire
Business Name or DBA
Owner's Name
First Name
Last Name
Owners Date of Birth
-
Month
-
Day
Year
Date
Business Type
LLC
Sole Proprietorship
Other
Primary Contact Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
FEIN
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Business Detail
Type of Work / Business
Please Select
Contractor - Commercial Building
Contractor - Residential Building
Contractor - Residential Renovations
Cleaning/Janitorial Services
Drywall Installation
Excavating
Finish Carpentry
Floor Covering Installation
Handyperson
Heating and Cooling Installation (HVAC)
Landscaping
Lawn Care Maintenance
Masonry
Painter
Pest Control Services
Plumber
Restoration Services
Roofer
Septic Services
Tree or Arborist Services
Well Drilling
Mobile Repair Service
Other
Please Indicate the Services Provided
Do you have employees?
Yes
No
Number of Full Time
Number of Part Time
Estimated Annual Payroll
Annual Subcontractor Cost
Estimated Annual Revenue
Would you like coverage for owned Tools and Equipment?
Yes
No
Please provide additional equipment details
Does your business own or lease any vehicles or trailers?
Yes
No
Number of Vehicles
Number of Trailers
Please provide additional details
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Operations Information
Are you required to provide a Certificate of Insurance?
Yes
No
Does your business involve pesticide, herbicide or fertilizing spraying?
Yes
No
Do you perform tree trimming, cutting, or removal?
Yes
No
Does your operations include replacement or repair of roofs?
Yes
No
Do you perform work outside of Michigan?
Yes
No
Please provide the States you do work in
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Do you currently have insurance coverage?
Yes
No
Have you been insured the past 3 years?
Yes
No
Name of current Insurance Carrier
Have you had any claims in the last 3 years?
Yes
No
Has any prior insurance policy been cancelled or non-renewed?
Yes
No
Please provide any additional details or information:
Submit
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