ARTISAN CONTRACTOR WORKSHEET

 

First Name:

Last Name:

Business Name:

Address:

City:

State:

California

Zip Code:

Phone Number:

Fax Number:

E-Mail Address: 

 

UNDERWRITING INFORMATION

 

Number of Owners:

 

Number of Employees:

Payroll of Owners:

Payroll of Employees:

Total Annual Gross Receipts:

Total Annual Sub Costs:

Current Insurance Company:

Select Your Classification:

Contractors License Number:

License Type:

Years of Experience:

How many years have you operated under your current business name:

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:

Percentage % of work done as a SUB-CONTRACTOR:

Percentage % of work done on RESIDENTIAL:

Percentage % of work done on COMMERCIAL:

Percentage % of work done for REMODELING:

Percentage % of work done for RENOVATION:

Percentage % of work done for REPAIR - MAINTANENCE:

Losses-Claims in the last 5 years: 

 

If yes, Date, Amount Paid & Description of each Loss-Claim

Liability Limits Requested: 

 

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Thank you for your interest.