| Applicant: |
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DBA: |
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| Business Address: |
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| Contact Phone: |
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Fax: |
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| Years in Business: |
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Date Started: |
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Description of business/work preformed: |
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If less than three (3) years in business, please include a brief summary of past experience: |
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| 1. Any claims in the past five (5) years? |
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| 2. Any pending/current losses or claims? |
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If yes, please explain: |
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| Expiring Premium ($): |
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| 7. Residential - How many new starts do you anticipate in the coming year? |
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| Maximum number of new homes built in any one year? |
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| How many days per week does the owner spend on site? |
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| 8. Commercial - How many new buildings will you build as a general contractor next year? |
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| Maximum number built in any one year? |
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| How many days per week does the owner spend on site? |
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| 9. Do you work on any condos, townhomes, or duplex/triplexes? |
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Is any of the work on NEW condos/townhomes/duplexes? |
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If so, how many units per year? |
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Max living units per structure? |
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Any work under OCIP (Wrap)? |
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| 10. Do you work on any NEW tract developments? |
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If over 5 at any one time, how many? |
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| 11. Do you have a formal safety program? |
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| 12. Any construction management or offering management services on a consultant basis? |
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| If so, do you carry professional liability Errors and Omission Coverage? |
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| 13. Any work on student housing, assisted living facilities, or retirement homes? |
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| 14. Any structural work, including grading and excavation, on slopes greater than 30 deg? |
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| 15. Any work on retaining walls over six (6) feet in height? |
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| 16. Do you or your employees install, service or repair alarm or fire suppression systems? |
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| 17. Any abatement work or asbestos removal? |
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| 18. Are you involved in the sale, or application, of chemicals (e.g. herbicides, pesticides)? |
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| 19. Do you use EFIS in your construction? |
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| 20. Are you involved in any recreational or playground construction? |
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| 21. Are you involved in any smoke, fire, or water damage restoration? |
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| 22. Do you perform any work over three (3) stories in height? |
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| 23. Any shoring, underpinning, tunneling, cofferdam, or caisson work? |
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| 24. Do you or your employees perform any roofing work directly (not subbed out)? |
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| 25. Any unusual exposures/operations not covered by this application? |
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Please explain any 'yes' responses to questions 11-25 here: |
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Name: |
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Position: |
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