CONTRACTOR

CONTRACTOR'S INSURANCE & SURETY APPLICATION

ACKNOWLEDGEMENT

YOU ACKNOWLEDGE AND AGREE THIS APPLICATION WILL NOT GENERATE AN INSTANT, ONLINE INSURANCE QUOTE. ONCE COMPLETE, THE INFORMATION WILL BE USED TO PROCESS QUOTES THAT WILL BE EMAILED TO YOU. THE PROCESS WILL GENERALLY TAKE LESS THAN 1 BUSINESS DAY BUT DIFFICULT TO RATE/PLACE RISKS MAY WAIT LONGER.

LINES OF COVERAGE YOU WANT QUOTED

GENERAL LIABILITY PROPERTY & CONTRACTORS EQUIPMENT WORKERS' COMPENSATION CONTRACTORS LICENSE BOND COMMERCIAL AUTO UMBRELLA LIABILITY (Only Available when General Liability is Selected)

SECTION I. GENERAL INFORMATION

Email Address

TELEPHONE NUMBER

COMPANY

CONTACT PERSON

MAILING STREET ADDRESS

CITY

STATE

ZIP CODE

FEDERAL EMPLOYER ID #

CONTRACTORS' LICENSE NO.

RESPONSIBLE MANAGING OFFICER (RMO)

RMO SOCIAL SECURITY NO.

Required for License Bond Applicants

LOCATION ADDRESS DIFFERENT THAN MAILING ADDRESS

LOCATION STREET ADDRESS

LOCATION CITY

LOCATION STATE

ZIP CODE

SECTION II. INSURANCE HISTORY

N/A FOR SELECTED COVERAGES

DO YOU HAVE CURRENT COMMERCIAL GENERAL LIABILITY INSURANCE

YES NO

EXPIRATION DATE OF CURRENT OR MOST RECENT GENERAL LIABILITY INSURANCE

CURRENT COMMERCIAL GENERAL LIABILITY INSURER

YEARS OF CONTINUOUS, UNINTERUPTED COMMERCIAL GENERAL LIABILITY INSURANCE

NUMBER OF GENERAL LIABILITY CLAIMS THE LAST 5 YEARS

DO YOU HAVE CURRENT WORKERS' COMPENSATION INSURANCE

YES NO

EXPIRATION DATE OF CURRENT OR MOST RECENT WORKERS' COMPENSATION POLICY

CURRENT WORKERS' COMPENSATION INSURER

YEARS OF CONTINUOUS, UNINTERUPTED WORKERS' COMPENSATION INSURANCE

NUMBER OF WORKERS' COMPENSATION CLAIMS THE LAST 5 YEARS

SECTION III. GENERAL & UMBRELLA LIABILITY

N/A Coverages Not Selected

LIABILITY INELIGIBLE OPERATIONS

HAVE YOU REVIEWED THE ABOVE LIST OF INELIGIBLE OPERATIONS AND ARE YOU ELIGIBLE?

YES NO

DO YOU DO WORK ON ANY NEW (PRIOR TO CERTIFICATE OF OCCUPANCY) RESIDENTIAL PROJECTS?

YES NO

# OWNERS ACTIVE IN FIELD

GROSS ANNUAL SALES

AMOUNT SUBCONTRACTED

CLASSIFICATION OF OPERATIONS & PAYROLL - ADD UP TO FIVE DIFFERENT CLASSIFICATIONS

CLASSIFICATION 1

ESTIMATED ANNUAL EMPLOYEE PAYROLL FOR CLASSIFICATION 1

CLASSIFICATION 2

ESTIMATED ANNUAL EMPLOYEE PAYROLL FOR CLASSIFICATION 2

CLASSIFICATION 3

ESTIMATED ANNUAL EMPLOYEE PAYROLL FOR CLASSIFICATION 3

CLASSIFICATION 4

ESTIMATED ANNUAL EMPLOYEE PAYROLL FOR CLASSIFICATION 3

CLASSIFICATION 5

ESTIMATED ANNUAL EMPLOYEE PAYROLL FOR CLASSIFICATION 5

SECTION IV. WORKERS' COMPENSATION

N/A Coverage Not Selected

WC INELIGIBLE OPERATIONS

HAVE YOU REVIEWED THE ABOVE LIST OF INELIGIBLE OPERATIONS AND ARE YOU ELIGIBLE?

YES NO

ARE ANY OWNERS INCLUDED IN WORKERS' COMPENSATION COVERAGE

YES NO

IMPORTANT: You must include an annual minimum of $45,500 and a maximum of $117,000 in the appropriate class payroll for each included owner. If an included owner's payroll is between those values, use their actual annual compensation. DO NOT include payroll for excluded owners.

WORKERS COMPENSATION CLASS CODE 1

ANNUAL PAYROLL FOR CLASS

WORKERS COMPENSATION CLASS CODE 2

ANNUAL PAYROLL FOR CLASS

WORKERS COMPENSATION CLASS CODE 3

ANNUAL PAYROLL FOR CLASS

WORKERS COMPENSATION CLASS CODE 4

ANNUAL PAYROLL FOR CLASS

WORKERS COMPENSATION CLASS CODE 5

ANNUAL PAYROLL FOR CLASS

SECTION V. COMMERCIAL AUTO

N/A Coverage Not Selected

AUTO INELIGIBLE EXPOSURES

HAVE YOU REVIEWED THE ABOVE LIST OF INELIGIBLE OPERATIONS AND ARE YOU ELIGIBLE?

YES NO

ANY DRIVERS WITH MORE THAN 2 MOVING VIOLATIONS OR WITH ANY MAJOR (DUI, ETC) VIOLATIONS IN 5 YEARS

YES NO

# OF VEHICLES

# OF DRIVERS

MILES VEHICLES TYPICALLY TRAVEL FROM YOUR LOCATION

VEHICLE # 1 IDENTIFICATION NUMBER ("VIN' - 17 CHARACTERS)

VEHICLE # 2 IDENTIFICATION NUMBER ("VIN' - 17 CHARACTERS)

VEHICLE # 3 IDENTIFICATION NUMBER ("VIN' - 17 CHARACTERS)

VEHICLE # 4 IDENTIFICATION NUMBER ("VIN' - 17 CHARACTERS)

VEHICLE # 5 IDENTIFICATION NUMBER ("VIN' - 17 CHARACTERS)

VEHICLE # 6 IDENTIFICATION NUMBER ("VIN' - 17 CHARACTERS)

VEHICLE # 7 IDENTIFICATION NUMBER ("VIN' - 17 CHARACTERS)

VEHICLE # 8 IDENTIFICATION NUMBER ("VIN' - 17 CHARACTERS)

VEHICLE # 9 IDENTIFICATION NUMBER ("VIN' - 17 CHARACTERS)

VEHICLE # 10 IDENTIFICATION NUMBER ("VIN' - 17 CHARACTERS)

SECTION VI. PROPERTY & EQUIPMENT

N/A Coverage Not Selected

PROPERTY INELIGIBLE EXPOSURES

HAVE YOU REVIEWED THE ABOVE LIST OF INELIGIBLE OPERATIONS AND ARE YOU ELIGIBLE?

YES NO

PROPERTY COVERAGE DESCRIPTIONS

CHECK THE TYPES OF PROPERTY YOU WOULD LIKE TO COVER

SEE PROPERTY COVERAGE DECRIPTIONS ABOVE FOR HELP

BUILDING VALUE

OFFICE CONTENTS VALUE

MISC TOOLS & SMALL EQUIP (<$1,500 / ITEM)

COMPUTER SYSTEMS - HARDWARE VALUE

COMPUTER DATA & MEDIA VALUE

COMPUTER EXTRA EXPENSE VALUE

SCHEDULED EQUIPMENT LIGHT/MED VALUE

SCHEDULED EQUIPMENT HEAVY VALUE

INSTALLATION FLOATER VALUE

RENTED/LEASED EQUIPMENT VALUE