| Personal Information |
| First Name
Required
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| Last Name
Required
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| Number of Owners
Required
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| Name(s) of Company Owner(s), with % ownership
Required
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| Description of Operations:
Required
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| Formal Name of Business
Required
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| Is your company a franchise?
Required
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| If yes, provide full legal name of franchisor:
Optional
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| Business Type
Required
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| Street
Required
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| City
Required
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| State
Required
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| ZIP / Postal Code
Required
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| Primary Phone Number
Required
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| E-Mail Address
Required
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| Website Address:
Required
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| Year Established
Required
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| How many years of experience do you have?
Required
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| Do you perform services in the State of New York?
Required
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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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| Please list all States in which you operate.
Required
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| Estimated Annual Gross Revenue
Required
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| Prior 12 months annual gross revenue
Required
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| Number of full-time employees
Required
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| Number of part-time employees
Required
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| Number of temporary/ seasonal employees
Required
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| Number of independent contractors
Required
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| By category, provide estimated annual payroll paid to: owners, employees, temporary/seasonal and independent contractors.
Required
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| Do you use subcontractors?
Required
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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. |
| What percentage of your work includes the subcontracting of work to others?
Required
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| Annual Cost of Subcontractors
Required
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| Are subconsultants and subcontractors hired under a written, standard subcontract?
Required
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| Does your company use a standard written contract with clients?
Required
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| Do you get this contract signed 100% of the time?
Required
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| Does your contract contain a limitation of liability and an aribtration clause?
Required
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| Do you provide written warranties for your work?
Required
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| Do you use subcontractors?
Required
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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. |
| What percentage of your work is subcontracted to others?
Required
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| Annual Cost of Subcontractors
Required
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| Does your company use a standard written contract with clients?
Required
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| Do you get this contract signed 100% of the time?
Required
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| Advise if your contracts contain these items:
Required
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Hold down the Ctrl Key to make multiple selections. |
| Does your contract contain a limitation of liability and an aribtration clause?
Required
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| Do you provide written warranties for your work?
Required
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| How many years have you continuously had Professional Liability (E&O) coverage?
Required
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| Effective Date
Optional
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| Current Policy End Date
Required
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| Current Limits
Required
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| Current Deductible
Required
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| Current Premium
Required
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| Has any entity proposed for insurance closed, sold, merged with or acquired any company in the past 12 months or anticipates doing so in the next 12 months?
Required
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| Does the firm currently have General Liability Insurance in place?
Required
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| If yes, please provide name of General Liability insurer and approximate expiration date:
Required
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| Number of E&O insurance claims filed with insurance carriers in the last 5 years:
Required
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| Do you have knowledge of any circumstance, act, error, or omission that could result in a professional liability claim?
Required
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| Has Professional Liability (E&O) insurance ever been non-renewed or cancelled?
Required
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| Additional Comments
Optional
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Submission Validation Required |
Enter the Validation Code from above.
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