Artisan Contractor




Requested effective Date
[date* date-107 id:datepicker]

Insured Type

Name

Company name

Contact person's name

Contact person's phone
- -

( ### )        ###            ####

Mobile
- -

( ### )        ###            ####

Fax
- -

( ### )        ###            ####

Email

License #

License Type

Mailing address (if different)

City

State

ZIP

Physical Address

Current Insurance?

Name of insurance company

Current premium

Losses in past three years?
 Yes No

Limits of liability

Deductible

Years in business

Years Experience

% Residential

Must Equal 100%

% Commercial

% New Construction

Must Equal 100%

% Remodel

Anticipated gross receipts for coming year

Do you sub out work? If so, what do you sub out?

Describe the type of work done by the applicant

Number of full time employees

Number of part time employees

Annual payroll

Do you work on condominiums, townhouses, apartments or tracts over 5 units except for repair or remodeling of not more than one unit at a time within a development?

Do you subcontract more than %40 of your operation?

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