| 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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Brief description of business/work: |
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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 three (3) 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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| 6. Any heat application? (Circle) |
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| 7. If so, what percentage of your operations are: |
a) Hot tar |
% |
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b) Foam application |
% |
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c) Torchdown |
% |
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d) Other |
% |
| 8. What percentage of your work is: |
a) General Contractor |
% |
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b) Sub-contractor |
% |
| 9. What percentage of your work is: |
a) Commercial |
% |
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b) Residential |
% |
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c) Industrial |
% |
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d) Other (describe) |
%
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| 10. What percentage of your work is: |
a) New construction |
% |
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b) Remodel/Repair |
% |
| 11. On a typical project, what percentage of your work is performed by |
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a) Your employees |
% |
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b) Leased employees |
% |
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c) Sub-contractors under your supervision |
% |
| 12. Any construction management or offering management services on a consultant basis? |
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| 13. If so, do you carry professional liability Errors and Omission Coverage? |
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| 14. Any work on student housing, assisted living facilities, or retirement homes? |
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| 15. Do you or your employees install, service or repair alarm or fire suppression systems? |
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| 16. Any abatement work or asbestos removal? |
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| 17. Are you involved in the sale, or application, of chemicals (e.g. herbicides, pesticides)? |
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| 18. Do you use EFIS in your construction? |
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| 19. Are you involved in any smoke, fire, or water damage restoration? |
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| 20. Do you perform any work over three (3) stories in height? |
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| 21. Any unusual exposures/operations not covered by this application? |
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| 22. Do you always require your subcontractors to sign a hold-harmless or indemnification agreement in your favor? |
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| 23. Do you utilize a standard contract with all of your subcontractors? |
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| 24. Do you require your subcontractors to carry General (Public) Liability insurance? |
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| 25. Do you require that you are named as an Additional Insured on their policies? |
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Please explain any 'yes' responses to questions 12-25 here: |
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Name: |
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Position: |
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