| Personal Information |
| First Name
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| Last Name
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| Nature of Business
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| Formal Name of Business
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| Provide other names which you have conducted business
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| Business Type
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| Street
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| City
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| State
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| ZIP / Postal Code
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| Primary Phone Number
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| E-Mail Address
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| Year Business Established
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| Please list all States in which you operate.
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| Contractor License Number:
Optional
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| What year was this license issued?
Optional
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| CONTRACTING OPERATIONS (select all that apply)
Required
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| Please provide % breakdown (must add up to 100% for each category above)
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| How many years of experience do you have?
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| Number of Employees
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| 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
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| Estimated Annual Gross Revenue
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| Prior 12 months annual gross revenue
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| Description of largest job(s) in last 3 years.
Optional
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| About how much do you pay your subcontractors each year?
Required
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| What % of your overall work involves installation?
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| Amount of Desired Insurance
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| Do you currently have insurance?
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| Prior Insurance
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| Current Premium
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| Current Insurance Provider
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| Effective Date
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| Current Policy End Date
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| How many insurance claims have you filed in the last 5 years for these specific services?
Required
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| Please select the type(s) of client you have:
Required
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| Please provide % breakdown (must add up to 100% for each category above)
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| What percentage of your work is done inside vs. outside?
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| Do you perform services in the State of New York?
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| If “Yes,” what percentage is performed in the five (5) boroughs and what percent in the rest of New York?
Optional
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| Does your company use a standard written contract with clients?
Required
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| If you do not use a standard contract, how are non-standard client agreements reviewed?
Required
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| Does your contract contain a limitation of liability and an aribtration clause?
Required
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| If so, what percentage of contracts contain this clause?
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| Do you use subcontractors?
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| When hiring subcontractors, check off all that apply:
Required
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Hold down the Ctrl Key to make multiple selections. |
| Are subconsultants and subcontractors hired under a written, standard subcontract?
Required
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| Any past, present or future work on hillsides, hilltops or terraces?
Optional
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| Any past, present or future work on landfill areas or in subsidence areas?
Required
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| Any past, present or future construction operations conducted in excess of 2 stories?
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| Any past, present or future exterior work performed above 2 stories in height from grade?
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| Any past, present or future work performed below grade?
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| Any past, present or future involvement in the construction of condos, townhouses or apartments?
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| Any past, present or future involvement in the building of Tract Housing Developments? (Tract defined as 6 or more homes in the same subdivision)
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| Do you draw any plans or blueprints used in your construction work?
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| Have you ever been named in a construction defect suit?
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| Do you have a formal safety program in operation?
Required
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| Any past, current, or planned involvement in: (check all that apply)
Optional
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| Do you own lease any heavy equipment?
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| 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
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| 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?
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| 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?
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| How did you hear about us?
Optional
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| Additional Comments
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