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%):
(Total should
equal 100%):
In What Capacity
Do You Operate? (Total should equal 100%):
Where Do You
Operate? (Total should equal 100%):
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:
