First Name: |
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Last Name: |
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Business Name: |
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Address: |
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City: |
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State: |
California |
Zip Code: |
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Phone Number: |
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Fax Number: |
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E-Mail Address: |
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UNDERWRITING
INFORMATION |
Number of Owners: |
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Number of Employees: |
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Payroll of Owners: |
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Payroll of Employees: |
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Total Annual Gross Receipts: |
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Total Annual Sub Costs: |
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Current Insurance Company: |
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Select Your Classification: |
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Contractors License Number: |
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License Type: |
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Years of Experience: |
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How many years have you operated under your current business name: |
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Have you used any other business names during the past 5 years: |
NoYes |
Have you been involved in the original construction or remodeling
of town homes, condos, row homes or developments of 15 or more
unattached single family dwellings during the past 5 years: |
NoYes |
Do you construct footings or foundations which may support
dwellings or other structures: |
NoYes |
Do you construct slab or monolithic floors: |
NoYes |
Do you construct piers or underpinning which may support dwellings
or other structures: |
NoYes |
Do you construct retaining walls which may support dwellings or
other structures: |
NoYes |
Do you construct fireplaces or chimneys: |
NoYes |
Percentage % of work done as a GENERAL CONTRACTOR: |
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Percentage % of work done as a SUB-CONTRACTOR: |
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Percentage % of work done on RESIDENTIAL: |
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Percentage % of work done on COMMERCIAL: |
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Percentage % of work done for REMODELING: |
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Percentage % of work done for RENOVATION: |
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Percentage % of work done for REPAIR - MAINTANENCE: |
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Losses-Claims in the last 5 years: |
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If yes, Date, Amount Paid & Description of each Loss-Claim |
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Liability Limits Requested: |
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Please
press the Submit Button ONCE.
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Thank you for your interest.
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