Subcontractor Application
Company Name
*
Trade
*
Owner's Name
*
Address
*
City
*
State
*
Zip Code
*
Primary Contact
*
Contact Phone
*
Company Phone
Email Address
*
Website
Organization Information
(for Parnership, LLC or Corporation)
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State Company is Organized
*
Fed Tax ID#
*
Years in Business
*
Number of Employees
*
Is your firm owned or controlled by another organization?
*
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Do you currently carry, or can you obtain Workers Compensation Insurance Coverage ($500,000 policy limit/$100,000 per employee per incident)?
*
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What state(s) do you have Workers Comp. coverage in?
*
Do you currently carry, or can you obtain General Liability Insurance coverage ($100,000)?
*
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Insurance Company
*
Policy Number
*
Insurance Agent
*
Agency Address
*
Agency City, State,Zip
*
Agent Phone
*
Company Name (Reference #1)
*
Date (Ref #1)
*
Contact Name(Ref #1)
*
Phone (Ref #1)
*
Project (Ref #1)
*
Scope of Work (Ref #1)
*
Company Name (Reference #2)
*
Date (Ref #2)
*
Contact Name (Ref #2)
*
Phone (Ref #2)
*
Project (Ref #2)
Scope of Work (Ref#2)
*
Company Name (Reference #3)
*
Date (Ref #3)
*
Contact Name (Ref #3)
*
Phone (Ref #3)
*
Project (Ref #3)
*
Scope of Work (Ref #3)
*
Completed By
*
Title
*
Contact Number
*
Date Completed
*
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