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 - Complete if Residential or Remodeler
Contractor
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- Complete if Trade Contractor
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 - Complete if requesting this coverage
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
Tarpey Insurance. We will respond to you promptl y.
General Questions/Comments:
