Contractors Supplemental Application
Please complete all sections as accurately as possible. Your information is sent securely to your agent.
Section I — General Information
Basic business and contact information.
Financial History
Provide financial information for the last 5 years and estimates for next year.
| Period | Direct Payroll ($) | # Employees | Subcontractor Costs ($) | Gross Receipts ($) |
|---|---|---|---|---|
| Next Year (Est.) | ||||
| Last Year | ||||
| 2nd Year Prior | ||||
| 3rd Year Prior | ||||
| 4th Year Prior | ||||
| 5th Year Prior |
Section II — Business Type & Work Breakdown
Select all that apply and provide work percentage estimates.
| Work Type | % Direct | % Subbed | Work Type | % Direct | % Subbed |
|---|---|---|---|---|---|
| Airport Runways | % | % | Painting | % | % |
| Blasting | % | % | Plastering | % | % |
| Bridge Work | % | % | Plumbing | % | % |
| Carpentry | % | % | Roofing | % | % |
| Concrete | % | % | Seismic Retrofitting | % | % |
| Demolition | % | % | Sewer | % | % |
| Drilling | % | % | Steel / Ornamental | % | % |
| Drywall | % | % | Steel / Structural | % | % |
| Earthquake | % | % | Street / Road | % | % |
| Electrical | % | % | Supervisory Only | % | % |
| Excavation | % | % | Traffic Signals | % | % |
| Grading | % | % | Water / Gas Mains | % | % |
| HVAC | % | % | Other (describe in notes) | % | % |
| Insulation | % | % | Maintenance | % | % |
| Masonry | % | % | Mechanical | % | % |
Project Details & Operations
Describe your largest projects and answer operational questions.
Condominium / Townhouse details:
Subcontractors & Loss History
Section III and Section IV of the application.
Section III — Subcontractor Information
Section IV — Loss / Claim History
Section V — Signature & Agreement
Please read the statement below and sign to complete your application.
This Application is the basis for coverage; therefore, any incorrect or incomplete statements or answers could nullify coverage. Completion of this form neither binds coverage nor guarantees that a policy will be issued.
I hereby request that my application for insurance coverage be submitted for consideration. I authorize any person or organization to release information that may relate to my insurability.
I hereby indicate that the aforementioned statements and answers are correct and complete. I understand that an incorrect or incomplete statement could void my protection.
NOTICE TO CALIFORNIA APPLICANTS:
For your protection, California law requires the following to appear on this form: Any person who knowingly presents false or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
NOTICE TO ALASKA, ARIZONA, CONNECTICUT, DELAWARE, GEORGIA, HAWAII, IDAHO, ILLINOIS, INDIANA, IOWA, KANSAS, MASSACHUSETTS, MICHIGAN, MINNESOTA, MISSISSIPPI, MISSOURI, MONTANA, NEBRASKA, NEVADA, NEW HAMPSHIRE, NORTH CAROLINA, NORTH DAKOTA, SOUTH CAROLINA, SOUTH DAKOTA, TEXAS, UTAH, VERMONT, WASHINGTON, WISCONSIN, AND WYOMING APPLICANTS:
In some states, any person who knowingly, and with intent to defraud any insurance company or other person, files an application for insurance or statement of claim containing any materially false information, or, for the purpose of misleading, conceals information concerning any fact material thereto, may commit a fraudulent insurance act which is a crime in many states.
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