Type of company:
Select OneCorporationPartnershipSole ProprietorshipLimited Liability Company
Federal tax ID#:
Does the company have any union agreements? YesNo
Is your firm certified? YesNo
If yes, please check all that apply:MBEWBESBEDBEDVBELSDBEOTHER
Certifying Agency (s):...............Certification Number (s)
Are you able to bond projects?: YesNo
Single project limit:
Bonding company address:
Agent phone number:
Experience Modification Rate (EMR) for the past three years:
1st prior year:
2nd prior year:
Does the company have a written safety program and/or policies?YesNo
Does the company have a written drug policy?YesNo
Does the company employ a full-time safety professional?YesNo
In the last three years has the firm been cited for any serious (defined by OSHA) Violations?YesNo
Acknowledge you have the following minimum coverage: YesNo
Workers Compensation Insurance: Statutory Coverage in state where work is being done.
100,000 each accident
100,000 disease each employee
500,000 disease policy limit
1,000,000 each occurrence.
1,000,000 products and completed operations.
1,000,000 any auto, hired and non owned.
Umbrella or Excess Liability:
1,000,000 each occurrence
Insurance company address: