CONTRACTORS
PERSONAL INFORMATION
* Mandatory fields
Quote Date :  
First Name : *
Last Name : *
Mailing Address : *
City : *State: * Zip Code: *
Home No. : *
Cell No. : *
Business No. :
E-Mail. :
Current Policy Expiration Date :
Social Security No. :
Location of Garage :
(if diff. from Above)
City : State : Zip Code :
Choose from the Following:
COMPLETE SUPPLEMENTAL QUESTIONNAIRE
Is this questionnaire for :   
If “renewal” give current policy number :  
INSURED
When did the applicant's business start?  
How long has the applicant been in this line of work? :  
Is or has the applicant ever been involved in any other business venture as an owner or officer?

explain:

 
. Has this business or any other business in which the insured is or was involved as an owner or officer ever declared bankruptcy?    if Yes
explain:  
What classes of contractors licenses does the applicant hold?  
License number(s) :  
 
EMPLOYEES
Provide the following information concerning employees for the past three years and give an estimate for the next 12 months:
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Number of Full-time Employees
Number of Part-time Employees
 
PAYROLL AND RECEIPTS

Provide the following information for the past three years (use audited information if possible) and give an estimate for the next 12

Year
Total Receipts
Payroll (excluding partners and officers)
$
$
$
$
$
$
Estimate
$
$
 
Commercial : %
 New   Repair or Remodelling  New Residential  New commercial
Residential : %
 New   Repair or Remodelling  New Residential  New commercial
Industrial : %
 New   Repair or Remodelling  New Residential  New commercial
 
 
 
 
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