Contractor Questionnaire

Contractor Questionnaire

Need assistance over the phone? Call Jamie at 863-534-3431"Be Wise Economize"
Company*
For Internal Proposes only

I am ready to take FORDNS
What type of entity are you?*

LLCINCSole proprietorship
Do you have a " Doing Business As" Name

YesNo
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?

MonthDayYear
Date
Address Mailing*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is your mailing address the same as your physical address?*

YesNo
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
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*

HVACElectricalInsullationPlumbingRoofingPoolExcavationGradingDebris CleanuplandscapingMasonryPaintingCarpentryTileFlooringRemodelingPressure Washing
Do you perform Soft wash Roof cleaning*

YesNo
Does your pressure washer go above 4000 PSIs?*

YesNo
How many stories do you go up to?*
If Applicable: Contractor License Number*
Give the percentage breakdown of commercial vs residential construction work that you perform*
What are your projected gross sales per year*
Have you been involved in or are you aware of pending litigation concerning defective workmanship?*
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?*
Please Select
Explain any work that was answered yes from above ( If applicable)*
Are you involved in any other business besides contracting?*
Please Select
How many employees do you have?*
What is your projected payroll (excluding owners) for the upcoming year*
Do you hire subcontractors?*
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?*

YesNo
In would like a quote on the following lines of business to protect my company ( CHECK ALL THAT APPLY)*

General Liability: Coverage that can protect you from a variety of claims including bodily injury, property damage, personal injury to othersWorkers 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 ITInland Marine: Coverage for your equipment that moves with you.Commerical Auto
Do you have a vendor that is requiring insurance?*

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?*

YesNo
How Did you hear about us?*

GoogleReferral from a friendSign on BuildingFacebook/GiveawayI know agent personally
FOR INTERNAL NOTES ONLY: Does this qualify for a BOP?

YesNo
What is your home address?*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I opt in to receive text and email **

YesNo
Should be Empty: