Full Business Name
Website address. If none, state NONE.
Email address. If none, state NONE.
FEIN# or SS#
Years in business under present name:
Years of experience in this field:
CONTRACTING OPERATIONS (select all that apply)
Artisan Contractor General Contractor Developer Owner/Builder Subcontractor Construction Manager Consultant
Please provide % of fees attibutable to each operations stated above. (example: General Contractor 100%)
Have you operated under any other names?
If yes, please explain.
Present or prior affiliation with any other firms?
Contractor License Number:
What year was the license issued?
Who is your present insurer? If you do not have coverage currently, state NONE.
If currently insured, what are your limits of liability? If none, state NONE.
If currently insured, what is your deductible or SIR? If none, state NONE.
If you have a claims made policy, what is your retroactive date? If none, state NONE.
Has any insurer ever cancelled, restricted or refused to renew your General Liability policy?
Please list all States in which you operate.
Please provide a list of your 5 largest jobs, include date job completed, type of work performed and job cost:
Provide the gross sales, payroll and subcontract costs projected for this year:
Provide the gross sales, payroll and subcontracted costs for the most recent 12 months:
Provide the gross sales, payroll and suncontracted costs for the 12 month period that ended 24 months ago:
Provide the gross sales, payroll and subcontracted costs for the 12 month period that ended 36 months ago:
Provide the gross sales, payroll and subcontracted costs for the 12 month period that ended 48 months ago:
Provide the gross sales, payroll and subcontracted costs for the 12 month period that ended 60 months ago:
Types of construction operations:
New Construction Commercial Remodeling Residential Repair Industrial Demolition Instiutional Other
Provide % for each of the above selected operations. (Total to equal 100%)
Provide % of overall work performed as either residential or commercial work. (Total to equal 100%)
What % of your overall work involves installation?
Indicate employee payroll and subcontractor costs for each type of work performed: (example: Electrical: EP:$25,000 SUB:$5,000)
Any past, present or future work on hillsides, hilltops or terraces?
Any past, present or future work on landfill areas or in subsidence areas?
Any past, present or future construction operations conducted in excess of 2 stories?
Any past, present or future exterior work performed above 2 stories in height from grade?
If yes, what is the maximum # of stories and percentage of total work?
Any past, present or future work performed below grade?
If yes, what is the maximum depth and percentage of total work?
Any past, present or future involvement in the construction of condos, townhouses or apartments?
If yes, please explain:
Any past, present or future involvement with EIFS or Synthetic Stucco?
Any past, present or future involvement in the building of Tract Housing Developments? (Tract defined as 6 or more homes in the same subdivision)
Average # of homes built projects completed annually:
Average cost of job?
Have you worked or will you or your employees work under USL&H or Jones Act?
Do you have a formal safety program in operation?
Please explain, we will need a copy prior to binding.
Do you use subcontractors?
What is the percentage of subcontracted work?
What are the annual subcontracting costs? (including all subs’ labor and materials)
Are certificates of insurance obtained from subcontractors?
What are the minimum limits you require from the subcontractors?
Are written contracts obtained from all subcontractors which include a hold harmless clause in your favor?
If no, explain when not required:
Do you draw any plans or blueprints used in your construction work?
If yes, has Professional Liability Coverage been obtained?
What is the Professional Liability limit purchased?
Do you own any vacant land held only for investment of possible development more than 12 months future?
If yes, is the property zoned as residential or non-residential?
Do you own any real estate development property (land with improvements-streets, roads or utilites, etc….completed under construction?
Total # of acres of vacant land?
Total # of acres of Real Estate Dev Prop:
Do you have any other operations other than mentioned here? If yes, explain below:
Have you had any claims the last 5 years?
If yes, the currently valued hard copy loss runs will be required prior to binding. Please provide a loss summary below. For each of the preceeding 5 years, please provide the # of Claims, # of Claims Still Open,Total Paid, and Total Reserved.
Any subsidence or sinkhole related losses in the past 5 years?
Have you ever been named in a construction defect suit?
If yes, provide details:
Are you aware of any other incidents which may result in claims against you?
If yes, please give details:
Do you have a Commercial Auto policy under this company name?
Do you have a Workers Compensation policy under this company name?
Would you like a quick quote for Employment Practices Liability?
Please utilize the “Send” Button to send your form to our office. If the website does not allow you to submit the form, please print the page and fax it to 732.334.0405 or scan it into your computer and send it to email@example.com. Do not “Refresh” the page because all data entered onto the form will be lost.
After you hit the “Send” button, please scroll back down to this area and if successfully sent, a message will appear below. If not successfully sent, a message will appear below which means you have to scroll back up and complete the missing information, which typically involves entering information into a highlighted box. Complete the missing information and then hit “Send” again. Thank you!
Your First Name (required)
Your Last Name (required)
Your Email (required)
Re-Enter Your Email (required)
Name Of Your Company or type of business if seeking commercial insurance (required)
Street Address (required)
Zip Code (required)