Please enable JavaScript in your browser to complete this form.APPLICANT INFORMATIONPlease fill in the fields belowApplicant's NameName *FirstLastLocation AddressMailing AddressTime in business:Years of experience:Licensed?YESNOYear of license:License #:Kind of License:2. Percentage of Operations:General ContractorSubcontractorConstruction ManagerDeveloperWith Penalty Clause(for a fee only)3. Are there any other operations owned, operated, or managed by you?YESNOPlease explain:Is coverage in place elsewhere for these operations?YESNO4. Does any of your construction management work involve supervision of subs whose contracts and payments are not directly under your control?YESNOPlease explain:5. Radius of operations from main location:States worked in:6. Payroll of owners, officer, and partners active at job sites or performing supervisory dutiesPayroll of employees other than owners, officers, partners, and clericalCost of leased, temporary, staffing service, casual labor (if not included above)Total payroll7. Do you employ any licensed architects, surveyors, engineers, Real Estate agents or brokers?YESNO8. Do you have any prior or planned jobs covered under “wrap-up” or OCP policies?YESNOPlease explain:9. List the percentage of work you have done or plan to do in the following categories:Overall operations:CommercialPublic WorksResidential Otherexplain:COMMERCIAL you on Homes NewNewor Remodelor RemodelIndustrialInstitutionalMercantileOfficeRemodeling – StructuralRemodeling – NonstructuralOther:RESIDENTIALNewNewor Remodelor RemodelApartmentsCondominiums/Townhouses Custom HomesTract HomesRemodeling – StructuralRemodeling – NonstructuralOther:Have you ever been or are currently involved in any residential project exceeding twenty (20) homes/units?YESNO10. SUBCONTRACTORSDo you obtain Certificates of Insurance for GL and WC from all subcontractors?YESNOWhat are the minimum General Liability limits you require?Are written contracts obtained from all subcontractorsYESNODo all contracts contain a Hold Harmless clause in your favor?YESNOAre you named as an Additional Insured on all subcontractor policies?YESNODo you normally use the same subcontractors?YESNODo you use any casual labor?YESNODo you use any leased employees? If yes, provide copy of contractYESNOAre you responsible for providing benefits, Worker’s Compensation for these employees?YESNOWhat percentage of your work do you sub out?YESNODo you carry Worker’s Compensation insurance?YESNO11. Please provide your gross sales for each of the 5 past years and an estimate for the next 12 months:Fill out the fields belowYEARPAYROLLRECEIPTSSUBCONTRACTORS COST5th prior yearPAYROLL $PAYROLL $RECEIPTS $RECEIPTS $SUBCONTRACTORS COST $SUBCONTRACTORS COST $4th prior yearPAYROLL $PAYROLL $RECEIPTS $RECEIPTS $SUBCONTRACTORS COST $SUBCONTRACTORS COST $3rd prior yearPAYROLL $PAYROLL $RECEIPTS $RECEIPTS $SUBCONTRACTORS COST $SUBCONTRACTORS COST $2nd prior yearPAYROLL $PAYROLL $RECEIPTS $RECEIPTS $SUBCONTRACTORS COST $SUBCONTRACTORS COST $Last yearPAYROLL $PAYROLL $RECEIPTS $RECEIPTS $SUBCONTRACTORS COST $SUBCONTRACTORS COST $Projected next 12 monthsPAYROLL $PAYROLL $RECEIPTS $RECEIPTS $12. Describe your three largest projects currently underway or planned for the next year, including values:Fill out the fields belowStart DateStart DateEnd DateEnd DateValue $Value $DescriptionDescriptionStart DateStart DateEnd DateEnd DateValue $Value $DescriptionDescriptionStart DateStart DateEnd DateEnd DateValue $Value $DescriptionDescription13. Describe your four largest projects over the past five years, including values:Fill out the fields belowYear CompletedYear CompletedValue $Value $DescriptionDescriptionYear CompletedYear CompletedValue $Value $DescriptionDescriptionYear CompletedYear CompletedValue $Value $DescriptionDescriptionYear CompletedYear CompletedValue $Value $DescriptionDescription14. Please provide the dollar value of an average completed job (including all materials, equipment, and labor):15. How many additional insured endorsements do you anticipate needing in the next year?16. Is there any equipment rental to others?YESNOIf yes, sales/receipts:List equipment:Attach a copy of the contract17. Do you lease mobile equipment?YESNOWith operators?YESNOType of equipment:Do you use cranes?YESNOMaximum length of boom:18. Do you or have you performed repairs of fire damage, water damage, or mold damage?YESNO19. Do you use explosives?YESNOIf yes, please explain:20. Any flammables stored on site?YESNOIn approved containers?YESNOIf yes, please explain: 21. Have you done or do you plan any work performed for:RefineriesYESNOChemical PlantsYESNORailroadsYESNOPublic UtilitiesYESNOGas StationsYESNOAirportsYESNOHospitalsYESNOplease explain:22. Have you done or do you plan any project involving:CaissonsYESNORetaining WallsYESNOUnderpinningYESNOPiersYESNOShoringYESNOOther structural engineering?YESNOplease explain:23. Have you in the past or do you plan any work to be above two stories in height?YESNOPercentage:%What is the maximum depth?Please explain:24. Have you in the past or do you plan any work to be performed below ground level?YESNOPercentage: %What is the maximum depth?Please explain: 25. Have you in the past or do you plan any work on hillsides, hilltops, slopes, or landfills?YESNOMaximum degree of slope:26. Have you in the past or do you plan any repair, replace or new roofs?YESNOPercentage of heat applications:%Percentage of membrane roofing:%Please explain:27. In the past three years, have you been fired or replaced on a job in progress?YESNOHave you replaced another contractor on a job in progress?YESNOPlease explain: Were there any claims, losses, or suits against you in the past five years?YESNOAre there any claims or legal actions pending against any of the entities named in the application?YESNODo any of the entities named in the application have knowledge of any pre-existing act, omission, event, condition, or damage to any person or property that may potentially give rise to any future claim or legal action?YESNOHave you been accused of faulty construction in the past five years?YESNOHave you been accused of breaching a contract in the past five years?YESNO28. Complete the following table as applicable:Abatement/Asbestos, Lead, Environmental CleanupClass$Subbed Cost $%Subbed Cost %$Employee payroll $%Employee payroll %-NoneAIR CONDITIONING/HEATINGClass$Subbed Cost $%Subbed Cost %$Employee payroll $%Employee payroll %-NoneALARM SYSTEMSClass$Subbed Cost $%Subbed Cost %$Employee payroll $%Employee payroll %-NoneBLASTINGClass$Subbed Cost $%Subbed Cost %$Employee payroll $%Employee payroll %-NoneSubmit87565
