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Business Information
Applicant Name
Business / Entity Name
Business Address
City
State
Zip Code
Business Phone
Contact Email
Years in Business
Years of Experience in Plumbing
Business Structure
-- Select --
Individual
Partnership
Corporation
LLC
Joint Venture
Are you licensed?
-- Select --
Yes
No
Contractor's License Number
Financial Overview
Projected Gross Revenue
Upcoming policy term
# Active Owners
Employee Payroll
Excluding owners
Estimated Annual Subcontracting Cost
Plumbing Operations & Specifics
Breakdown of Work Type (Must equal 100%)
% Residential
% Commercial
% Industrial
Total percentage must equal 100%. Current:
0
%
% General Contractor
% Subcontractor
Do you perform any gas line work or hook-ups?
-- Select --
Yes
No
Gas Line Follow-up:
Any boiler work related to gas lines?
No
Yes
Any welding operations?
No
Yes
High-pressure steam pipe work related to gas lines?
No
Yes
Any boiler work? (install/service/repair)
-- Select --
Yes
No
Any high-pressure steam pipe work?
-- Select --
Yes
No
If you indicated Industrial work, what type of clients?
Does your work involve repair or remodeling?
-- Select --
Yes
No
What % of total operations?
Any condo conversions?
No
Yes
Any remodeling for condos/HOAs?
-- Select --
Yes
No
Is this for the association or individual owners?
Subcontractor Management
Do you hire subcontractors?
No
Yes
Require COIs before starting?
Yes
No
Do you utilize written contracts with all subs including indemnification/hold harmless in your favor?
Yes
No
Use 1099 laborers?
No
Yes
Carry Workers Comp?
Yes
No
What specific jobs are they hired for?
Risk & Cross-Trade Questions
Any known loss/claim involving mold or construction defect?
No
Yes
Please describe:
Perform fire/water restoration?
No
Yes
Handle hazardous materials?
No
Yes
Perform Roofing?
No
Yes
Perform HVAC work?
No
Yes
Maximum building height (feet):
What States do you perform work in?
Quote Options
Current GL Carrier (if any)
Any GL claims in the last 3 years?
No
Yes
Please describe claims:
Would you like a Workers Comp Quote?
No
Yes
# Full-Time Employees
# Part-Time Employees
Estimated WC Payroll
Preferred Payment Plan
Monthly
Annual
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