Applicant
Information
Company
Name:
Your
Name:
Street
Address:
City/State/Zip:
/
/
Home
Phone:
Work
Phone:
Email:
General
Information
Organization
Type:
Individual
Partnership
Corporation
Other
other:
Contractor
Type:
Please Select Type
Air Conditioning
Appliances & Accessories - Commercial
Appliances & Accessories - Household
Carpentry
Carpentry - Interior
Carpentry - Residential (< 3 Stories)
Ceiling or Wall Installation - Metal
Communication Equipment Installation
Concrete Construction (Includes Foundations)
Door or Window Installation
Driveway Paving
Drywall or Wallboard Installation
Electrical Work - Within Buildings
Excavation
Fence Erection Contractors (No Dealers)
Floor Covering - Not Tile or Stone
Glaziers (No Motor Vehicles)
Grading of Land
Heating/Combined Heating and AC - No LPG
Heating/Combined Heating and AC
Landscape Gardening
Masonry
Metal Erection - Dwellings 2 Stories or Less
Metal Erection - Nonstructural
Metal Erection - Decorative
Painting - Exterior (3 Stories or Less)
Painting - Interior
Paperhanging
Plastering or Stucco Work
Plumbing - Commercial
Plumbing - Residential
Prefabricated Building Erection
Roofing - Residential
Septic Tank Systems - Installation/Service/Repair
Siding Installation
Sign Erection, Installation or Repair
Tile or Stonework - Interior
Water Well Drilling
Any
operation or property that is owned, leased or occupied that is
not covered by this policy?
Yes
No
If
Yes, please describe:
Have
you declared bankruptcy or had any financial problems in the past
7 years?
Yes
No
If
Yes, please describe:
Do
you perform more than 10% of your work in a state other than your
state of domicile?
Yes
No
If
Yes, please describe:
Total
number of employees(Owners/
Total
number of employees(not including
Total
payroll:
$
Number
of years experience:
Percentage
of work performed within 50 miles of your base of operations:
Amount
of sales receipts for current year:
$
Amount
of sales receipts for prior year:
$
Percentage
of work which is residential :
Percentage
of work which is commercial:
Complete
if Residential or Remodeler Contractor
Do
you require to be named as an Additional Insured on the subcontractor's
policy?
Yes
No
If
No, please explain:
Do
you ever act as a Construction Manager?
Yes
No
If
Yes, annual fees:
$
General
Liability
Any
owned autos?
Yes
No
Do
you build/remodel condominiums or multi-family dwellings?
Yes
No
If
Yes, please describe:
Do
you build/remodel commercial buildings exceeding 10,000 square feet?
Yes
No
If
Yes, please describe:
Number
of Housing Starts: Current
Year Prior
Year
Percentage
of work which is New Construction:
Percentage
of work which is Remodeling:
General
Liability
Do
you have any owned autos?
Yes
No
Do
operations include tunneling or trenching work deeper than 3 feet?
Yes
No
If
Yes, please describe:
Do
you contact utility services prior to digging or working with overhead
wires?
Yes
No
If
No, please explain:
Do
you perform dam or levee work or have you done so in the last 10
years?
Yes
No
If
Yes, please describe:
Do
you perform work at landfill sites or have you done so in the last
10 years?
Yes
No
If
Yes, please describe:
Do
you perform any railroad track/trackbed construction, repair or
maintenance or have you done so in the last 10 years?
Yes
No
If
Yes, please describe:
Do
you install any automatic sprinkler or fire suppression systems
or have you done so in the last 10 years?
Yes
No
If
Yes, please describe:
Do
you install fire alarms or smoke detectors or have you done so in
the last 10 years?
Yes
No
If
Yes, please describe:
Do
you install or repair gas mains(excluding hose connections) or have
you done so in the last 10 years?
Yes
No
If
Yes, please describe:
Do
you install, service or repair high pressure boiler systems or have
you done so in the last 10 years?
Yes
No
If
Yes, please describe:
Do
you apply "Exterior Insulation Finish Systems"(a/k/a "Synthetic
Stucco") or have you ever done so in the past?
Yes
No
If
Yes, please describe:
Any
remodeling involving foundation, structural changes or movement
of load bearing walls?
Yes
No
If
Yes, please describe:
Minimum
General Liability limits required of subcontractors:
$
$ A
Contractors
Equipment
Any
Mobile Equipment?:
Yes
No
If yes, please complete below.
Does
operator have less than 2 years experience in operating the equipment?
Yes
No
If
Yes, please comment:
Does
this mobile equipment have any maintenance program in place?
Yes
No
If
Yes, please describe:
Is
equipment secured and protected when not in use?
Yes
No
If
Yes, please describe:
Thank
You! You've
completed the form. Be sure you've included your name and company
name and email address. If you have any general questions
or comments, please enter them in the box below, then click the
submit button. Thank you for considering Ideal Insurance. We will
respond to you promptly.
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