Secured by SSL

Contractors Online Application


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Personal Information
First Name
Required
Last Name
Required
Nature of Business
Optional
Formal Name of Business
Required
Provide other names which you have conducted business
Optional
Business Type
Required
Street
Required
City
Required
State
Required
ZIP / Postal Code
Required
Primary Phone Number
Required
E-Mail Address
Required
Year Business Established
Required
Please list all States in which you operate.
Required
Contractor License Number:
Optional
What year was this license issued?
Optional
CONTRACTING OPERATIONS (select all that apply)
Required


Hold down the Ctrl Key to make multiple selections.
Please provide % breakdown (must add up to 100% for each category above)
Required
How many years of experience do you have?
Required
Number of Employees
Required
Indicate projected 12 month owner payroll, employee payroll and subcontractor costs for each type of worker: (example: Owner $80,000, Employee $40,000 Electrical Sub $25,000)
Required
Estimated Annual Gross Revenue
Required
Prior 12 months annual gross revenue
Required
Description of largest job(s) in last 3 years.
Optional
About how much do you pay your subcontractors each year?
Required
What % of your overall work involves installation?
Required
Amount of Desired Insurance
Required
Do you currently have insurance?
Required
Prior Insurance
Required
Current Premium
Required
Current Insurance Provider
Required
Effective Date
Required
/ /
Current Policy End Date
Required
/ /
How many insurance claims have you filed in the last 5 years for these specific services?
Required
Please select the type(s) of client you have:
Required


Hold down the Ctrl Key to make multiple selections.
Please provide % breakdown (must add up to 100% for each category above)
Required
What percentage of your work is done inside vs. outside?
Required
Do you perform services in the State of New York?
Required
If “Yes,” what percentage is performed in the five (5) boroughs and what percent in the rest of New York?
Optional
Does your company use a standard written contract with clients?
Required
If you do not use a standard contract, how are non-standard client agreements reviewed?
Required


Hold down the Ctrl Key to make multiple selections.
Does your contract contain a limitation of liability and an aribtration clause?
Required
If so, what percentage of contracts contain this clause?
Required
Do you use subcontractors?
Required
When hiring subcontractors, check off all that apply:
Required


Hold down the Ctrl Key to make multiple selections.
Are subconsultants and subcontractors hired under a written, standard subcontract?
Required
Any past, present or future work on hillsides, hilltops or terraces?
Optional
Any past, present or future work on landfill areas or in subsidence areas?
Required
Any past, present or future construction operations conducted in excess of 2 stories?
Required
Any past, present or future exterior work performed above 2 stories in height from grade?
Required
Any past, present or future work performed below grade?
Required
Any past, present or future involvement in the construction of condos, townhouses or apartments?
Required
Any past, present or future involvement in the building of Tract Housing Developments? (Tract defined as 6 or more homes in the same subdivision)
Required
Do you draw any plans or blueprints used in your construction work?
Required
Have you ever been named in a construction defect suit?
Required
Do you have a formal safety program in operation?
Required
Any past, current, or planned involvement in: (check all that apply)
Optional












Do you own lease any heavy equipment?
Required
In the past 5 years, has any claim, suit, or notice of incident been made against your firm, a predecessor firm or an organization for which your firm has assumed liabilities?
Required
In the past 5 years, has any member of your firm or a related entity aware of any circumstances that could result in a claim, suit or notice of incident being brought against them?
Required
Has applicant, or any affiliated, related or predessor entity ever been (or is currently) the subject of bankruptcy, reorganization, solvency, dissolution, or other debtor proceeding, or has it made an assignment for the benefit of creditors?
Required
How did you hear about us?
Optional
Additional Comments
Optional
Submission Validation
Required
CAPTCHA
Change the CAPTCHA codeSpeak the CAPTCHA code
 
Enter the Validation Code from above.
Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.
Location
Mailing Address Only
P.O. Box 868
Oakhurst, NJ 07755
Facebook Twitter LinkedIn Google Maps
© Copyright 2020. All rights reserved.
Powered by Insurance Website Builder