Name:* First Last Phone Number:*Email:* Address:* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Also called "Street Address", or where you receive your mail. No PO Box numbers, please.Company Name:*Business Email:* Business Address:* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code About the Company:What best describes your business's ownership structure?* Select All Individual / Sole Proprietorship Partnership Limited Liability Company Corporation Trust Other Entity Please describe the other entity:*What year did you start your business?*What is your Federal Employee Identification Number (FEIN)?*Number of executive officers:*Number of employees (do not include owners, subcontractors, or independent contractors):*Expected subcontractor cost in the next 12 months:*Enter $0 if you do not expect to hire subcontractors.About the Business:Please list out the activities your employees perform e.g Landscaping, tree trimming removal, basic clerical, or administrative work, installing drywall.*Only include W-2 employees. Do not include owners, subcontractors, cash, or 1099 workers. We will ask about these later.What is your expected employee payroll for the selected activities over the next 12 month?*Only include W-2 employees. Do not include owners, subcontractors, cash, or 1099 workers.Would you like to add insurance coverage for owners, partners or executives?*YesNoAbout the Work:Has your commercial insurance coverage been canceled, revoked, or non-renewed in the last 3 years (other than cancellation for non-payment or non-renewal for discontinuation of program)?*YesNoHas your business, or any of its officers, owners, or partners been convicted of a felony in the past 5 years?*YesNoHas your business, or any of its officers, owners, or partners declared bankruptcy in the past 3 years?*YesNoHas your business, or any of its officers, owners, or partners had business-related lawsuits, mediations, or arbitrations filed against them?*YesNoBecome aware of any losses, accidents, or circumstances that might give rise to a claim against this policy?*YesNoHas your business had any serious OSHA violations in the past three years?*YesNoDoes your practice include work in lumbering and log hauling?*YesNoDoes your practice include work in subway, shall sinking or tunneling?*YesNoDoes your practice include work in subaqueous work?*YesNoDoes your practice include work in caisson or cofferdam work, dam, lock or revetment construction?*YesNoDoes your practice include work in past or present work with exposure to asbestos, dioxin or polychlorinated biphenyls?*YesNoDoes your practice include work in transportation of hazardous materials?*YesNoDoes your practice include work in work at depth greater than 6 feet and heights greater than 30ft?*YesNoDoes your practice include work in blasting, demolition or wrecking?*YesNoDoes your practice include work in dismantling of buildings or vessels?*YesNoDoes your practice include work in 24-hour operations?*YesNoDoes your practice include work on municipal power lines?*YesNoDoes your practice include work in foundry, abrasive, or sandblasting work?*YesNoDo you have more than once office location?*YesNo
