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Prior General Liability Carrier Information: (In order to ensure that proper credits/debits are applied to
this account, prior carrier information must be provided).
No
Policy
Insurance
Insurance
Policy # or
Term
Coverage
Company Name
MGA/Wholesaler
Premium
Current Term
[_]
$
Prior Term #1
[_]
$
Prior Term #2
[_]
$
Prior Term #3
[_]
$
Prior Term #4
[_]
$
Claims History: (Description of Losses or No Claims or Losses)
Policy
Number
Term
of Claims
Total Amount of Losses
Current Term
$
Prior Term #1
$
Prior Term #2
$
Prior Term #3
$
Prior Term #4
$

No
Claims or Losses
[_]
[_]
[_]
[_]
[_]

Business Operations: (Questions 1 - 4)
1. What percentage of your work is (each column must add to 100%)
Structure
Type
Residential
Industrial
Commercial

Percentage
of Work
%
%
%

Construction
Type
New Construction
Structural remodel/additions
Service and Repair
Non-structural Remodel

Percentage
of Work
%
%
%
%

2. Gross Receipts for the next 12 months and last 3 years:
Next 12 Months
Last 12 Months
2nd Year Prior
3nd Year Prior

$
$
$
$

Not Applicable
Not Applicable
Not Applicable

3. Please list your largest current/planned job and your largest job in the past 3 years:
2

Description of Largest Current/Planned Job
Value of job

$

Description of Largest Job In Last 3 Years:
Value of job
$
Not Applicable
4. Description Of Operations: (must be at least 10 words)

2