CONTRACTOR LIABILITY QUALIFICATION FORM

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Bolds Insurance Brokerage

1447 Fourth Street

San Rafael, CA  94901

Phone: (415) 485-1700  Fax: (415) 485-1866

 

BUSINESS NAME/ADDRESS

Business Name
Street Address
City/State/Zip
          -     

 

CONTACT INFORMATION

Name
Phone Number
Fax Number
Email Address

 

ENTITY TYPE

Describe-other

 

TYPE OF CONTRACTOR

Describe-other

 

Residential

Commercial

Industrial

Total

%

%

%

=100%

 

 

 

 

New Construction

Remodel

Additions

Total

%

%

%

=100%

 

 

Remodel

New

Annual Number

Single Family

yes no

yes no

new only

Apartment

yes no

yes no

new only

Condominium

yes no

yes no

new only

Townhouse

yes no

yes no

new only

 

LAST THREE LARGEST JOBS

Year

Contract Amount

Description of Project

$

$

$

 

PAYROLL, SUBCONTRACTED COSTS, GROSS RECEIPTS

 

Previous 12 Months

Next 12 Months

Payroll*

$

$

Sub Costs

$

$

Gross Receipts

$

$

*do not include payroll of owner(s)

 

OWNERS (partners, officers, members)

Number of Owners

Number of "Active"* Owners

* work at "jobsite"

*owners who work at the jobsite 

 

MISCELLANEOUS INFORMATION

Date Business Established

Contractors License Number

 

INSURANCE CERTIFICATES    we do not subcontract any work

Certificates Obtained From All Subcontractors yes no
Are You Named as  Additional Insured yes no
Liability Limits Requested on Certificate

 

INSURANCE COMPANY    no prior insurance

Insurance Company (current)

Policy Number

Expiration Date

 

CLAIM HISTORY no claims/past 4 years

Year (last 4)

Amount Paid

Construction Defect?

$

yes

$

yes

$

yes
$ yes

Are you aware of any situation which might result in a claim:

yes no   If yes, explain below:

 

DESCRIBE ALL CLAIMS/OR POTENTIAL CLAIMS

 

ARE YOU INTERESTED IN OTHER COVERAGE(S)

Workers Compensation yes no
Tool/Equipment Coverage yes no
Business Automobile yes no
Group Medical/Dental yes no

 

COMMENTS

 

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