Limits
of Liability Desired
300,000
500,000
1,000,000
2,000,000
Company
Name:
Owners
Name
Contractor
License Type:
Contractor
License Number(s)
Years
of Experience:
Years
in Business
Type
of Business:
sole proprietorship
partnership
corporation
Number
of active Current Owners/Partners/Officers
Street
Address:
City:
Telephone
State,
Zip:
Fax:
Email
Please
describe your operations in detail:
Gross
Receipts Including Labor & Material & Cost of Sub:
Cost
of Sub Including Labor & Material:
Payroll
Excluding Owners & Officers but Including Leased Labor:
Number
of full time employees:
Number
of part time employees:
Will
you use subcontractors?
If
yes, list trades of subcontractors used:
Average
value of projects:
Maximum
number of jobs running at same time:
Are
you currently insured?
If
no, please state reason for applying:
If
yes, who is your current carrier?
Policy
expiration date:
How
many years have you been continuously insured?
Any
claims in last 5 years?
Indicate
percentage of work performed
(Total
should equal 100%):
In
What Capacity Do You Operate?
Where
Do You Operate?
Describe
Your Involvement in New Ground Up Construction in Detail:
Maximum
number of new homes built in any one year:
Maximum
number of new houses planned to be built for next 12 months:
How
many homes in one location?
Do
you perform work above two stories in height?
If
yes, what is maximum stories?
Maximum
heights?
If
work is done for condo/town-home/apartment/PUD’s/tract homes,
is work done for:
Individual Unit Owner
General Contractor
Association
Other
Tell
us more about your Business:
