General Contractor




Ownership Type

Number of active owners

Business Name

License #

Applicant name

Mailing address

City

State

ZIP

Physical address

City

State

ZIP

Name of county

Phone
- -

( ### )        ###            ####

Mobile
- -

( ### )        ###            ####

Fax
- -

( ### )        ###            ####

Email





SECTION BREAK

Contact person's name

Contact person's phone
- -

( ### )        ###            ####

Limits of liability desired

Number of years in business

Number of years experience

Last year's annual gross receipts

Anticipated gross receipts for coming year

If you have any losses or claims, please describe with dates

Describe the type of work done by the applicant

% Residential

Must Equal 100%

% Commercial

% New Construction

Must Equal 100%

% Remodel

Anticipated cost of sublet work for coming year

If you sub out work, please describe

Number of full time employees

Number of part time employees

Annual payroll (other than owners)

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?

Are you customer home builder who builds more than 5 homes in any one year?

Do you have insurance now?

Current premium

Carrier name

Expire date
[date* date-901 id:datepicker]

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