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?
Annual
Payroll by classification,
Tell
us more about your Business:
