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| Fields marked (*) are mandatory. |
General Information |
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| Name of Business* |
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| Inspection Contact Name* |
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| Mailing Address* |
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| City* |
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| State* |
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| Zip* |
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| Location Address* |
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| City* |
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| State* |
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| Zip* |
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| Business Phone |
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| Fax |
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| Contact Email Address |
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| Business Status
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| Years in Business |
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| Current Insurance Information |
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| Company Name (not agency) |
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| Premium |
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| Effective Date |
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| Expiration Date |
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| Please List Any Other Previous Carriers Over the Past 3 Years Below: |
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| Carrier Name: |
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| Premium |
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| Carrier Name |
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| Premium |
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| Project/Work Information |
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| Pease write a Description of Operations |
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| What percentage of your work is (each line must total 100%) |
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| Commercial (%) |
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| Industrial (%) |
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| Residential (%) |
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| New Construction (%) |
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| Remodel/Additions (%) |
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| What percentage of your work is as a |
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| General Contractor (%) |
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| Subcontractor (%) |
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| What percentage of your work is |
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| Sub contracted Out (%) |
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| Sub Costs ($) |
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| Do you collect certificates of insurance at a $1,000,000 limit? |
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| Receipts / Payroll / Dollar Value Info |
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| Gross receipts for the past 3 years and the next 12 months |
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| (3rd yr prior) $ |
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| (2nd yr prior) $ |
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| (Last 12 mths) $ |
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| (Next 12 mths) $ |
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| Number of owners/officers/partners active at the job site or supervising |
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| Payroll of employees excluding owners, officers, partners & clerical ($) |
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| Dollar value of average job completed incl. all materials, lab or & equipment ($) |
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| describe any projects) underway or planned for the next year, including values |
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| Miscellaneous and Legal Info |
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| Have you ever performed ground up construction involving condominiums, townhouses, apartments, or single family tract developments of two (2) or more? |
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| Have you ever been named in litigation regarding faulty construction? |
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| Are there any claims or legal actions pending? |
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| Do any of the entities name din the application have knowledge of any pre-existing act, omission, event, condition or damages to any person or propert |
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| Claims History |
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| Enter all claims or occurrences that may give rise to claims for the prior 3 years. This information is kept strictly confidential |
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| Claim #1 |
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| Claim Status: |
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| Date of Occurrence |
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| Date of Claim |
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| Type/Description of Occurrence or Claim |
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| Amount paid on your behalf: |
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| Amount reserved on behalf: |
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| Claim #2 |
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| Claim Status: |
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| Date of Occurrence |
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| Date of Claim |
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| Type/Description of Occurrence or Claim |
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| Amount paid on your behalf: |
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| Amount reserved on behalf: |
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| Additional Comments |
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| Please give any additional comments you feel appropriatefor this quotation. |
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