Lange Insurance

1. General Information

Contractor License Number

Insured/Contact Name

Company Name

Phone

Fax

E-mail Address

Policy Term Requested

Mailing Address

Street Address

City

State

Zip

Premise Address

2. Payroll excluding Owners, Officers & Clerical

Job Class

Expected Annual Payroll

Hourly Wage

Gross receipts for the next 12 months and last 12 months

Next 12 months $

Last 12 months $

3. Describe your operations

Operations Description

4. Coverage Information

Do you have coverage currently?

Yes

If yes, include Company, Policy number, Expiration date:

Do you need any special coverages, requirements, company rating, or wording?

Yes

If yes, please describe:

5. Experience and Work

Years of experience in the contracting business:

Years in business of entities seeking coverage:

6. What percentage of your work is: (each line must add to 100%)

Residential %

Industrial %

Commercial %

New Construction %

Structural remodel/additions %

Non-structural remodel %

7. What percentage of your work is as a:

General Contractor %

Subcontractor %

Construction Manager %

Project Information

8. States in which you operate:

If not on the list, enter here:

9. Describe your two largest projects currently underway or planned for the next year, including values:

Project 1:

Project 2:

10. Describe your two largest projects over the past five years, including values:

Project 1:

Project 2:

11. Dollar value of average job completed (Including all materials, labor & equipment):

12a. How many new homes will you build as a general contractor in the next year?

12b. What is the greatest number of new homes you have built in any one year?

Additional Questions

13. The following question applies to work done in any capacity, including general contractor, developer, artisan, remodeling contractor, site work contractor, supplier, etc.

a. Have you or will you perform work involving, related to, or about the premise of: Condominiums or townhouses?

Yes

If yes to a, describe in detail:

14. Heavy structural engineering techniques

Have or will any of your projects involve caissons, cantilevers, piers, retaining walls, shoring, underpinning, or other heavy structural engineering techniques?

Yes

Description:

If retaining walls have been or will be built, maximum height:

15. Roof work

Have you or will you build, remove, repair or replace roofs?

Yes