General Information
Name of Business:
Inspection Contact Name:
Mailing Address:   City:	State:   Zip:
Location Address:   City:	State:   Zip:
Business Phone:	Fax:
Contact Email Address:
Business Status:	Individual Corporation Partnership Joint Venture     Years in Business:

Current Insurance Information
Company Name (not agency):	Premium: $
Effective Date:	Expiration Date:
Please List Any Other Previous Carriers Over the Past 3 Years Below:
Carrier Name:	Premium: $
Carrier Name:	Premium: $

Project/Work Information
Please write a Description of Operations below:
What percentage of your work is:  (each line must total 100%)	Commercial %  Industrial %  Residential %
	New Construction %   Remodel/Additions %
What percentage of your work is as a:	General Contractor: %   Subcontractor: %
What percentage of your work is:	Subcontracted Out: %   Sub Costs: $
Do you collect certificates of insurance at a $1,000,000 limit?:	Yes     No

Receipts / Payroll / Dollar Value Info
Gross receipts for the past 3 years:  and the next 12 months:	(3rd yr prior) $     (2nd yr prior) $ (Last 12 mths) $    (Next 12 mths) $
Number of owners/officers/partners active at the job site or supervising:
Payroll of employees excluding owners, officers, partners & clerical:	$
Dollar value of average job completed incl. all materials, labor & equipment:	$
Describe any project(s) underway or planned for the next year, including values below:

Miscellaneous and Legal Info
Have you ever performed ground up construction involving condominiums, townhouses, apartments, or single family tract developments of two (2) or more?:	Yes   No
Have you ever been named in litigation regarding faulty construction?:	Yes   No
Are there any claims or legal actions pending?:	Yes   No
Do any of the entities named in the application have knowledge of any pre-existing act, omission, event, condition or damages to any person or property that may potentially give rise to any future claim or legal action against any such entity?:	Yes   No

 

Claims History Enter all claims or occurrences that may give rise to claims for the prior 3 years. This information is kept strictly confidential

Claim #1	Claim Status: Closed   Open
Date of Occurrence:	Date of Claim:
Type/Description of Occurrence or Claim:
Amount paid on your behalf:	$   Amount reserved on behalf: $

Claim #2	Claim Status: Closed   Open
Date of Occurrence:	Date of Claim:
Type/Description of Occurrence or Claim:
Amount paid on your behalf:	$   Amount reserved on behalf: $

 

Additional Comments

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