Company Name (required)
Is company a DBA? YesNo
Company President/CEO Name
President/CEO Email
Contact Person for Insurance Requests (required)
Email
Phone Please enter a direct number if different from general company phone number
Extension (if applicable)
Contact Person for Accounts Receivable (required)
Contact Person for Estimating (required)
Phone (required)
Fax No.
Mailing Preference (required) Please SelectPhysical AddressPO Box
Physical Street Address (required)
City (required)
State (required) Select StateALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY
Zip Code (required)
PO Box (if applicable)
City
State Select StateALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY
Zip Code
Federal Tax ID/SS Number (required)
Form 1099 Required? YesNo
Entity Type (required) Please SelectIndividual/Sole Proprietor/DBAPartnershipC CorporationS CorporationLLC-C CorporationLLC-S CorporationLLC Partnership
Please provide Trace License #'s. Limits and Expiration Dates
Please Attach a copy of your W-9 Form (required) Accepted file types: PDF/DOC/DOCX/JPG
Please Attach a copy of your current business license Accepted file types: PDF/DOC/DOCX/JPG If company holds multiple licenses, please attach the license that includes your headquarter's location.
Year the Business was Founded (required)
Number of Employees (required)
Specific Services Provided (required)
Licensed to Work In - check all that apply (required) NCSCGA
What additional States are you authorized to perform work?
Maximum Travel Distance
What portions of work are self-performed & subcontracted? (required)
Insurance Agency (required)
Insurance Agent Name
Is the company insured? (required) YesNo
General Liability (required) Please SelectOur Policy Meets the RequirementsOur Policy does NOT Meets the RequirementsWilling to obtain proper insuranceNot Applicable
Auto (required) Please SelectOur Policy Meets the RequirementsOur Policy does NOT Meets the RequirementsWilling to obtain proper insuranceNot Applicable
Worker's Comp (required) Please SelectOur Policy Meets the RequirementsOur Policy does NOT Meets the RequirementsWilling to obtain proper insuranceNot Applicable
Umbrella (required) Please SelectWe DO NOT have an umbrella policyWe HAVE an umbrella policyNot Applicable
Please Attach Current Insurance Certificate(s) (required) Accepted file types: PDF/DOC/DOCX/JPG
This Business Qualifies As A (check all that apply):
Large Business (a major corporation with more than 500 employees)Women-Owned Small Business (a business at least 51% of which is owned by one or more women who are found to be disadvantaged and whose management and daily operations are controlled by such individuals)Veteran-Owned Small Business (a business at least 51% of which is owned by one or more Veterans and whose management and daily operations are controlled by such individuals)Service-Disabled Veteran-Owned Small Business (a business at least 51% of which is owned by one or more Veterans who have a service-connected disability that has been determined by the Department of Veterans Affairs or Department of Defense and whose management and daily operations are controlled by such individuals)Minority-Owned Small Business (a business at least 51% of which is owned by one or more minority individuals or other individuals found to be disadvantaged and whose management and daily operations are controlled by such individuals)
Do you have experience with LEED/green buildings? (required) YesNo
You do NOT have to be LEED certified to answer yes.
Safety Officer's Name (required)
Title (required)
What is your workers comp EMR (experience modification rate) for the past three (3) years?
Year (required) EMR (required)
Is your Company Bonded? (required) YesNo
Please list three clients who you have recently worked with and can attest to your expertise.
Company (required)
Contact Name (required) Phone (required) Email
Any Additional Information We Should Know?
I hereby certify that all of the information provided above is true and accurate.
Applicant's Name (required)
Applicant's Email (required)
Today's Date (required)
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