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| Name
of Business: |
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| Type of Business: |
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| Description of Business: |
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| Year Started: |
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Years experience in industry:
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| Tax ID # |
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PROFESSIONAL LIABILITY SECTION |
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Professional Liability Limits: |
$
($250,000 will be quoted if nothing is entered) |
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| Full Time Employees |
Part-Time?
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Number of Partners/Execs:
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WHAT
PERCENTAGE OF GROSS REVENUES COME FROM:
(must equal 100%):
Residential:
Hospitals:
Restaurants:
Hotels
Retail
Government
Other (describe)
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| Do you belong to
any professional associations (ASID, IDAA)? |
(if known) |
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Gross Receipts: |
Prior Year $
(if new business, write NEW) |
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Current
Year $
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Estimates for Next
Year $
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| Annual Payroll: |
$
(if none, write "none") |
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| Has the applicant
passed the NCID Qualification Exam? |
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| Are you involved
in the construction or installation aspects of projects? |
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| Are any owners or
employees Professional Engineers (PE)? |
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| Claims: |
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| Other: |
Do your customers sign a
contract or written agreement
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Tell
us about your last 3 jobs: What were your gross earnings, for whom
where they done, and what did you do? |
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COMMERCIAL GENERAL LIABILITY SECTION |
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General Liability Limits: |
$
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| Smoke Detectors: |
Sprinklers:
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Space Occupied (sq feet):
(location 1) |
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Total building space (sq feet):
(location 1) |
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Stories (location 1): |
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Year Building Built:
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Building Security System?
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Do you currently have insurance (if
yes, with what carrier?
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Current Premium:
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Do you have any other information
about your business, or comments that you would like to
share? Please place special requests here, such as extra coverage
for special items. |
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