Current Insurance Information
Company Name (not agency):	Premium: $
Effective Date:	Expiration Date:
Please List Any Other Previous Carriers Over the Past 3 Years Below:
Carrier Name:	Premium: $
Carrier Name:	Premium: $

Project/Work Information
Please write a Description of Operations below:
What percentage of your work is: (each line must total 100%)	Commercial  % Industrial % Residential %
	New Construction % Remodel/Additions %
What percentage of your work is as a:	General Contractor: % Subcontractor: %
What percentage of your work is:	Subcontracted Out: %  Sub Costs: $
Do you collect certificates of insurance at a $1,000,000 limit?:	Yes     No

Receipts / Payroll / Dollar Value Info
Gross receipts for the past 3 years:  and the next 12 months:	(3rd yr prior) $      (2nd yr prior) $ (Last 12 mths) $     (Next 12 mths) $
Number of owners/officers/partners active at the job site or supervising:
Payroll of employees excluding owners, officers, partners & clerical:	$
Dollar value of average job completed incl. all materials, labor & equipment:	$
Describe any project(s) underway or planned for the next year, including values below:

Miscellaneous and Legal Info
Have you ever performed ground up construction involving condominiums, townhouses, apartments, or single family tract developments of two (2) or more?:	Yes No
Have you ever been named in litigation regarding faulty construction?:	Yes No
Are there any claims or legal actions pending?:	Yes No
Do any of the entities named in the application have knowledge of any pre-existing act, omission, event, condition or damages to any person or property that may potentially give rise to any future claim or legal action against any such entity?:	Yes No

 

Claims History Enter all claims or occurrences that may give rise to claims for the prior 3 years. This information is kept strictly confidential
Claim #1	Claim Status: Closed   Open
Date of Occurrence:
Date of Claim:
Type/Description of Occurrence or Claim:
Amount paid on your behalf:	$
Amount reserved on behalf:	$

Claim #2	Claim Status: Closed   Open
Date of Occurrence:
Date of Claim:
Type/Description of Occurrence or Claim:
Amount paid on your behalf:	$
Amount reserved on behalf:	$

 

Additional Comments

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