| Business Name (dba): |
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Contact Person : |
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| Phone : |
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Fax: |
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| Contractor's license # : |
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| Management |
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| How long have you been in business? |
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Describe duties of owner(s): |
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| Does owner(s) or insured(s) lease, operate or are a subsidiary of any other business(es) other than the business applying for insurance? |
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| If so, are they to be insured under this policy? |
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If yes, please supply all details. If not, provide a Certificate of Insurance on all other operations: |
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| Number of years under current management? |
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| Trade Association Membership held? |
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If yes, please describe : |
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Employee Data |
Number |
Annual Payroll |
Owner(s) only |
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$
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Full Time |
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$
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Part Time |
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$
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Leased or Subcontracted Labor |
Number |
Annual Cost |
Leased Employees |
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$
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Independent Contractors |
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$
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| Operations: |
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| Projected annual receipts: |
$
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| Prior year's annual receipts : |
$
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| Does applicant or their subcontractors use explosives? |
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If yes, please describe : |
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| Does applicant make a thorough study of the subsurface, including identification of existing utility pipes and lines, prior to any digging? |
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| Is all self-propelled mobile equipment transported to job sites by trailer? |
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| If shoring is required on a job, does applicant use OSHA approved equipment and techniques? |
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| Does applicant have sufficient signs, barricades, and fences to keep non-employees at a safe distance from job sites and equipment? |
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Equipment is:
Owned
Rented |
| Does applicant do off-season snow plowing? |
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| If yes, annual receipts from snow plowing: |
$
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| Who do they plow for? |
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| Any equipment loaned, leased or rented to others? |
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If yes, please describe type of equipment and annual rental receipts: |
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| Does applicant subcontract work? |
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If yes, please state type of work : |
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| Are Certificates of Insurance for Work Comp and General Liability obtained from subcontractors? |
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| Do you require subcontractors to add you as an Additional Insured to their General Liability Policy? |
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Application courtesy of http://www.insurance-appllcations.com
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| Do any of your past or anticipated future contracts involve underground storage tank removal: tunneling; earthen dam construction; river channeling or re-channeling; mining; work on landfills; street or road construction; or water main, sewer or pipeline construction? |
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If yes, please describe : |
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| Does applicant prepare residential housing sites? |
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READ AND SIGN BELOW: |
I have reviewed this application for accuracy before signing it. As a condition precedent to coverage, I hereby state that the information contained herein is true, accurate and complete and that no material facts have been omitted, misrepresented or mis-stated. I know of no other claims or lawsuits against the applicant and I know of no other events, incidents or occurrences which might reasonably lead to a claim or lawsuit against the applicant. I understand that this is an application for insurance only and that completion and submission of this application does not bind coverage with any insurer. |
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Name: |
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Position: |
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Date: |
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