Section I — General Information

Basic business and contact information.

Applicant / Business Name *

Business Address *

City *

State *

Zip *

Phone *

Ext

Website

Years Under Current Management *

Years of Experience *

States Where You Do or Have Done Business *

Contractor's License Number

Union Member?

Describe All Business Operations *

Does applicant currently own or operate any other business?

Other business names / licenses used in the last 5 years (active or inactive)

Has applicant filed bankruptcy in the past 5 years?

Does applicant carry Workers' Compensation insurance on employees?

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.

2. Percentage of Work by Type — enter % Direct and % Subcontracted for each applicable type

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	%	%

3. Percentage by Project Type (must total 100%)

Commercial

Residential

Industrial

Public Works / Gov't

4. New Construction vs. Remodel/Repair (must total 100%)

New Construction

Remodel / Repair

5. Interior vs. Exterior (must total 100%)

Interior

Exterior

Project Details & Operations

Describe your largest projects and answer operational questions.

Subcontractors & Loss History

Section III and Section IV of the application.

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.

Full Legal Name (acts as signature) *

Title *

Date *

Contractors Supplemental Application