| Contact Name: |
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| Contact Email: |
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| Contact Phone: |
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| Contact Fax: |
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| Applicant Name: |
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| How many years experience do you have in the contracting business? |
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| Years in business of entities seeking coverage: |
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License Number: |
| How many years experience do you have in the contracting business? |
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| What percentage of your work is: (each group must add to 100%) |
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% Commercial
% Public works/government
% Industrial
% Residential
% New Construction
% Structural remodel/additions
% Non-structural remodels
% Interior
% Exterior
% General Contractor
% Construction Manager
% Developer/Spec builder
% Artisan contractor
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| Do you use subcontractors? |
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Yes No |
| Do you have any prior or planned jobs covered under "wrap-up or OCIP policies? |
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Yes No |
| States in which you operate |
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| Gross receipts for next 12 months: |
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| Number of owners and partners active at job sites or performing supervisory duties: |
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| Payroll of employees other than owners, officers, partners, and clerical: |
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| Do you perform work above two stories in height (other than interior remodeling)? |
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Yes No
If so, what percentage? %
Maximum height: ft
Description:
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| Do you perform any work below ground level? |
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Yes No
If so, what percentage? %
Maximum depth: ft
Description:
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| Have you or will you perform work related to the following: gas stations, refineries, chemical plants, airports, public utilities, railroads, or hospitals? |
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Yes No
Description:
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| Have there been losses, claims or legal actions against you in the past 5 years? |
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Yes No |
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