Download PDFContractor / Consultant Application Step 1 of 4 0% Name*Phone*Email* Address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Request Type*New BusinessRenewalCompany is an*IndividualPartnershipCorporationJoint VentureCoverage Requested* Select All Commercial General Liability Contractors Pollution Liability Professional Liability Pollution Liability Proposed Effective Date* Date Format: MM slash DD slash YYYY Proposed Retroactive Date Date Format: MM slash DD slash YYYY Limits of Liability*$1,000,000/$1,000,000$1,000,000/$2,000,000$2,000,000/$2,000,000Deductible*$2,500$5,000$10,000 History of CompanyDate Established Date Format: MM slash DD slash YYYY Have there been any acquisitions, consolidations, dissolutions or mergers?*NoYesIf yes, please explain:*Does the firm have: Subsidiaries A Parent Company Other Related Entities If yes, please explain:*Do you share employees:*YesNoIf yes, please explain*Which state(s) is work performed in:General LiabilityCarrier LimitsLimitsDeductibleEffective DatePremiumPollution LiabilityCarrier NameLimitsDeductibleEffective DatePremiumProfessional LiabilityCarrier NameLimitsDeductibleEffective DatePremiumEstimated Gross Revenue for next 12 months1st Prior Year RevenueFiscal Year Period StartFiscal Year Period End Contracting & ConsultingContracting OperationsSelect as many services that describe your company's operations and provide the project gross receipts as well as the % contracted.Contracting ServiceProjected Gross Receipts% Subcontracted Select Service TypeAsbestos and/or Lead AbatementCarpentry/FramingCrime Scene CleanupDemolition - InteriorDemolition/DismantlingDrillingDrywall/Wallboard InstallationEmergency Response CleanupFire Sprinkler Installation/MaintenanceGeneral ContractingLandfill ConstructionMedical Waste Recycling & DisposalMold AbatementPaintingRestoration Contracting (Fire/Water)RoofingTank & Pipe CleaningTank Installation/RemovalSoil ExcavationWaste Transportation – LiquidWaste Transportation – SolidVacuum Truck OperationsOther Consulting ServicesSelect as many services that describe your company's services and provide the project gross receipts as well as the % contracted.Consulting ServiceProjected Gross Receipts% Subcontracted Select Service TypeAir Quality TestingAlternative Energy System Design & ConsultingAsbestos/Lead Remedial Design & OversightConstruction ManagementEngineering ServicesEngineering Services - EnvironmentalEngineering Services - CivilEngineering Services - OtherEnvironmental Impact StudiesExpert WitnessGeology, Groundwater & HydrogeologyHealth & Safety TrainingLaboratory AnalysisMold Remediation Design & OversightPhase IPhase IIPhase IIIRegulatory ConsultingSurveyingTrainingWaste Arranging & BrokeringOther What percentage of your operations is performed by subcontractors?Are subcontractors required to name the applicant as an Additional Insured on their policy?YesNoDo you use a standard indemnity contract with your clients and subs?YesNo Claim HistoryDuring the past five (5) years, has the insured or any individual or entity proposed for coverage submitted to an insurer or producer any claims or notice of any fact, circumstance, situation, transaction, event, act, error or omission which they had reason to believe might or could reasonably be foreseen to give rise to a claim?*NoYesIf yes, please explain*Is the insured or any individual or entity proposed for coverage aware of any fact, circumstance, situation, transaction, event, act, error or omission which they have reason to believe may or could reasonable be foreseen to give rise to a claim against you or any person or entity for whom coverage is sought?*NoYesIf yes, please explain*During the past five (5) years, has the insured or any individual or entity proposed for coverage been subject to any disciplinary or enforcement actions?*NoYesIf yes, please explain*FRAUD WARNING: APPLICABLE TO ALL STATES Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is crime and shall also be subject to a civil penalty not to exceed five thousand dollars ($5,000) and the stated value of the claim for each violation. WARRANTY STATEMENT The undersigned authorized officer of the applicant declares that the statements set forth herein are true. The undersigned authorized officer agrees that if the information supplied on the application changes between the date of the application and the effective date of the insurance, he/she (undersigned) will immediately notify the insurer of such changes, and the insurer may withdraw or modify any outstanding quotations and/or authorization or agreement to bind insurance. Signing this application does not bind the applicant or the insurer to complete the insurance. NOTICE TO APPLICANTS Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any false information, or conceals for the purpose of misleading, information concerning fact material thereto, commits a fraudulent insurance act, which is a crime.Consent* I agree to the statements, warnings, and notices outlined above.Electronic Signature*Title*CAPTCHAPhoneThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.
