Applicant Information
Company
Name:
Your
Name:
Street Address:
City/State/Zip:
/
/
Home Phone:
Work Phone:
Email:
General Information
Organization Type:
Individual
Partnership
Corporation
Other
If other (please describe):
Contractor Type:
Please Select Type
Air Conditioning
Appliances & Accessories - Commercial
Appliances & Accessories - Household
Carpentry
Carpentry - Interior
Carpentry - Residential (< 3 Stories)
Ceiling or Wall Installation - Metal
Communication Equipment Installation
Concrete Construction (Includes
Foundations)
Door or Window Installation
Driveway Paving
Drywall or Wallboard Installation
Electrical Work - Within Buildings
Excavation
Fence Erection Contractors (No Dealers)
Floor Covering - Not Tile or Stone
Glaziers (No Motor Vehicles)
Grading of Land
Heating/Combined Heating and AC - No LPG
Heating/Combined Heating and AC
Landscape Gardening
Masonry
Metal Erection - Dwellings 2 Stories or
Less
Metal Erection - Nonstructural
Metal Erection - Decorative
Painting - Exterior (3 Stories or Less)
Painting - Interior
Paperhanging
Plastering or Stucco Work
Plumbing - Commercial
Plumbing - Residential
Prefabricated Building Erection
Roofing - Residential
Septic Tank Systems -
Installation/Service/Repair
Siding Installation
Sign Erection, Installation or Repair
Tile or Stonework - Interior
Water Well Drilling
Any
operation or property that is owned, leased or occupied that is not covered by
this policy?
Yes
No
If Yes, please describe:
Have
you declared bankruptcy or had any financial problems in the past 7 years?
Yes
No
If Yes, please describe:
Do you perform more than 10% of
your work in a state other than your state of domicile?
Yes
No
If Yes, please describe:
Total number of employees(Owners/
Total number of employees(not including
Total payroll:
$
Number of years experience:
Percentage of work performed within 50 miles of
your base of operations:
Amount of sales receipts for current year:
$
Amount of sales receipts for prior year:
$
Percentage of work which is
residential :
Percentage of work which is commercial:
Complete if Residential or
Remodeler Contractor
Do you
require to be named as an Additional Insured on the subcontractor's
policy?
Yes
No
If No, please explain:
Do you
ever act as a Construction Manager?
Yes
No
If Yes, annual fees:
$
General Liability
Any owned autos?
Yes
No
Do you
build/remodel condominiums or multi-family dwellings?
Yes
No
If Yes, please describe:
Do you
build/remodel commercial buildings exceeding 10,000 square feet?
Yes
No
If Yes, please describe:
Number of Housing Starts:
Current Year
Prior
Year
Percentage of work which is New
Construction:
Percentage of work which is Remodeling:
General Liability
Do you have any owned autos?
Yes
No
Do
operations include tunneling or trenching work deeper than 3 feet?
Yes
No
If Yes, please describe:
Do you
contact utility services prior to digging or working with overhead wires?
Yes
No
If No, please explain:
Do you
perform dam or levee work or have you done so in the last 10 years?
Yes
No
If Yes, please describe:
Do you
perform work at landfill sites or have you done so in the last 10 years?
Yes
No
If Yes, please describe:
Do you
perform any railroad track/trackbed construction, repair or maintenance or have
you done so in the last 10 years?
Yes
No
If Yes, please describe:
Do you
install any automatic sprinkler or fire suppression systems or have you done so
in the last 10 years?
Yes
No
If Yes, please describe:
Do you
install fire alarms or smoke detectors or have you done so in the last 10
years?
Yes
No
If Yes, please describe:
Do you
install or repair gas mains(excluding hose connections) or have you done so in
the last 10 years?
Yes
No
If Yes, please describe:
Do you
install, service or repair high pressure boiler systems or have you done so in
the last 10 years?
Yes
No
If Yes, please describe:
Do you
apply "Exterior Insulation Finish Systems"(a/k/a "Synthetic Stucco") or have
you ever done so in the past?
Yes
No
If Yes, please describe:
Any
remodeling involving foundation, structural changes or movement of load bearing
walls?
Yes
No
If Yes, please describe:
Minimum General Liability limits required of
subcontractors:
$
$
Contractors Equipment
Any
Mobile Equipment?:
Yes
No
If yes, please complete below.
Does operator have less than 2 years experience
in operating the equipment?
Yes
No
If Yes, please comment:
Does this mobile equipment have any maintenance
program in place?
Yes
No
If Yes, please describe:
Is equipment secured and protected
when not in use?
Yes
No
If Yes, please describe:
Thank You! You've
completed the form. Be sure you've included your name and company name and
email address. If you have any general questions or comments, please enter
them in the box below, then click the submit button. Thank you for considering
Pacheco Insurance. We will respond to you promptly.
General Questions/Comments:
