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Business Name:
Year Established:
Contratcor License #:
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Business FEIN/TAX ID#:
Description of Business/Operations:
Full Time Employees:
Part-Time Employees:
Seasonal Employees:
Total Emplyees:
Business Entity Type
Corporation
LLC
Partnership
Assosiation
Joint Venture
Individual
Other
Number of Locations
Franchise
Yes
No
Employee Health Plan Provided?
Yes
No
Employee Health Care Provider/Percentage Paid by Employer
Driving Radius
No Driving
Less than 50 miles
51-100 miles
101-250 miles
251-300 miles
Over 300 miles
Type of Vehicles
SUV
Truck
Van
Sedan
Tractor
Other
Number of Vehicles Used
Number of Drivers Used
Total Estimated Annual Payroll:
Payroll Per Classcode
Class Code
# Full-Time Employees
# Part-Time Employees
Annual Payroll
1
2
3
4
5
6
7
8
Officers/Owner Exclusion
Full Name
Title
% of Ownership
Included/Excluded
1
2
3
4
5
Explain ALL Interior/Exterior Work Preformed
Type of Machenery, Hand Tools, Lifts Used:
Percentage of Residential Business:
Percentage of Commercial Business:
Percentage of New Construction Business:
Percentage of Repair/Remodel Business:
Percentage of Work Preformed by Sub-Contractors:
Description of work preformed by Sub-Contractors:
Total Estimated Gross Reciepts:
Any Work Exterior Work Preformed Above 2 Stories
Yes
No
If yes explain:
Any Use of Cranes?
Yes
No
Any Use of Scaffold?
Yes
No
Any Concrete Tilt-Up Work?
Yes
No
Any Roof Exposure?
Yes
No
% Hot Tar Applied:
% Metal Roofing:
% Torch Applied:
% Polyurethane Spray Foam:
Do you have designated hot tar employees?
Yes
No
Is fire watch provided on any hot tar or torch applications?
Yes
No
Fire extinguishers or other fire suppression equipment available during hot tar or torch application?
Yes
No
Are pre-work roof inspections performed to confirm strength and weakness areas?
Yes
No
Are ladders tied off?
Yes
No
How are materials delivered to the roof?
Maximum Roof Pitch:
What types of Fall Protection Systems are used?
Warning Line System
Toe Boards
Gaurdrail System
Personal Fall Arrest System
Safety Monitoring System
Other
Any Hazardous Material Handeling Exposure?
Yes
No
Any Work Preformed 6ft Underground or 15ft Aboveground?
Yes
No
Max Height/Depth in feet:
Manual Lifting?
Under 50lbs
Over 50lbs
Include General Liability Quote
Yes
No
Desired Effective Date:
-
Month
-
Day
Year
Date
Loss History
Please Select
In Business under 3 years- No losses
In Business 3-5 years- No Losses
In Business 5+ years- No Losses
Have Losses
Coverage Limits:
Please Select
500/500/500
500/1000/500
1000/1000/1000
1000/2000/1000
1000/2000/2000
Medical Expense
Please Select
$5000
$10000
Fire Legal Liability
Please Select
$50000
$100000
Deductable (Per Claim)
Please Select
$500
$1000
$2500
$5000
$10000
Total Gross Receipts (Next 12 Months)
Sub-Contractor Costs (Next 12 Months)
Employee Payroll (Next 12 Months)
Owner Payroll and/or Draw (Next 12 Months)
Excess Liability Coverage
Please Select
None
1,000,000
2,000,000
3,000,000
4,000,000
5,000,000
Do you require subcontractors to have a written contract, provide certificates of insurance showing limits of liability equal to or greater than those on your policy:
Yes
No
No Use of Sub-Contractors
Any work on condominiums, townhouses, or Tract Develpoments with more than 15 units:
Yes
No
Any work with student housing, senior housing, assisted living facilities, or retirement homes involving more than one (1) individual unit within the development:
Yes
No
Work on slopes greater than 15 degrees or retaining walls higher than 6 feet:
Yes
No
Any installation or work with wood, coal, or waste oil‐burning stoves:
Yes
No
Any work involving mold, asbestos, environmental remediation, or herbicides/pesticides:
Yes
No
Any installation of fire extinguishing systems or monitoring of alarm systems:
Yes
No
Any work on railroads, traffic lights, airports, recreation facilities, petroleum plants, chemical facilities, elevators, escalators, retrofitting, or foundation repair/stabilization:
Yes
No
Any swimming pool installation, work with fiber optics, or tunneling operations:
Yes
No
Have you filed bankruptcy in the past 7 years:
Yes
No
During the past three years has any company ever cancelled, non‐renewed, declined, or refused to issue similar insurance:
Yes
No
Have you had any general liabilty insurance claims in the past 3 years:
Yes
No
Do you have knowledge of any event that may result in a general liability insurance claim:
Yes
No
Do you perform work on residential projects valued over $2 million
Yes
No
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