Name: |
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Company Name: |
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Contractor License Number: |
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Company Type: |
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Years of Experience In Class/Trade: |
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Year Company Established: |
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Counties Company Operates: |
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Company Address: |
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City: |
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Zip Code: |
(5 digits) |
Current Insurance Company: |
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Limits of Liability: |
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Expiration Date: |
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Claims In Last 3 Years: |
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Bankruptcy In Last 3 Years: |
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Do/Will You Work On NEW Multi Unit Construction: |
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If Yes, Please Define: |
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Do/Will You Work On NEW Tract Construction: |
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If Yes, Please Specify: |
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Do/Will You Own Development Property: |
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If Yes, What Will Be Developed: |
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Do/Will You Work On Condominiums: |
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If Yes, Please Clarify: |
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Did/Do You Own Any Other Business: |
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If Yes, What Type of Business: |
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Do/Will You Buy And Resell Real Estate: |
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Contractor Classification: |
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Work/Service You Provide By Majority: |
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If Developer/Builder, New Homes Next 12 Months: |
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Fully Describe ALL Your Operations: |
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Describe Work You Will Subcontract: |
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Owners/Officers/Partners Working In Field: |
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Number of FULL TIME (In Field) Employees: |
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FULL TIME (In Field) Annual Employee Payroll: |
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Number of PART TIME (In Field) Employees: |
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PART TIME (In Field) Annual Employee Payroll: |
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Annual Subcontracting Costs: |
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Annual Gross Sales/Receipts: |
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Any Specific Additional Insured Requirements: |
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If Yes, Endorsements Required: |
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Phone Number: |
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Fax Number: |
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Email Address: |
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