CONTRACTOR QUESTIONNAIRE
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1 CONTRACTOR QUESTIONNAIRE 1. of Firm: Fiscal Yr. End: (City) (State) (Zip) Contracting Specialty: Fax: 6. Contact Person: 7. Title: 8. Year Business Started: 9. Type of Business: Corp. Part. Prop. Sub. S. Corp. L.L. 10. State of Incorporation: 11. Area of Operation: 12. List the corporate officers, partners or proprietors of your firm: SS# Yr. of Birth Position Percent Owned of Spouse SS# 13. Will the above individuals and spouses personally indemnify Surety: If no explain: 14. Is there a buy/sell agreement among the owners of the business: 15. Is this agreement funded by life insurance: 16. Corp. Indemnity: 17. Cross/Corp. Indemnity: 18. How many people does your firm employ? 19. How many work crews? 20. Has your firm or any or its principals ever petitioned for bankruptcy, failed in business or defaulted so as to cause a loss to a Surety? If yes, please explain: THEGUARANTEEUS.COM 1 of 5
2 21. Is your firm or any of its owners or officers currently involved in any litigation: If yes, please explain: 22. What percentage of the firm s work is normally for: Government Agencies Private Owners 23. What percentage of the firm s work is normally subcontracted: 24. Are bonds required of subs: 25. What trades do you normally subcontract: 26. What is the largest amount of uncompleted work on hand at one time in the past: Amount: Year: 27. What is the largest job you expect to do during the next year? 28. What is the largest uncompleted program expected during next year? 29. What is your expected annual volume next year 30. What trades do you normally undertake with your own forces? 31. SIC CODE: 32. Do you lease equipment? 33. Type of lease: 34. What are the terms of the lease 35. of your CPA: Fax: Contact Person: 36. On what basis are taxes paid? Cash Completed Job Accrual of Completion 37. On what basis are financial statements prepared? Cash Completed Job Accrual of Completion 38. On what level of assurance are financial statements prepared? CPA Audit Review Compilation 39. How often are financial statements prepared? Annually Semi-Annually Quarterly Monthly 40. Do you have a full time accountant on staff? 41. Yrs. experience: 42. Are job cost records kept? 43. How often reviewed? 44. How often updated? 45. Do they show job detail? 46. Frequency? THEGUARANTEEUS.COM 2 of 5
3 47. of your Bank: Fax: Contact Person: 48. Amount of line of credit: 49. Expiration date? 50. What is the interest rate: 51. UCC Filing? 52. How is credit secured: 53. Is your firm union? 54. What is your firm s Dun & Bradstreet Number: 55. D & B Rating: 56. Pay Record: 57. Date of Rating: 58. Remarks: 58. Previous Bonding Companies Reason for Leaving 59. List five of your largest contracts Job Contract Price Gross Profit Completion Date Bonded: THEGUARANTEEUS.COM 3 of 5
4 60. List five of your major suppliers: Address Telephone Contact 61. List four subcontractors (or contractors if you are a subcontractor) that you do business with: : : : : 62. List three Architects you have done business with: : : : 63. List key personnel, foremen or supervisors: Position Yr. of Birth Yrs. Exper. Previous Employer THEGUARANTEEUS.COM 4 of 5
5 64. List any life insurance in effect on key personnel Beneficiary Amount Cash Value 65. Provide copy of your most current certificate of insurance. 66. List any subsidiaries and affiliates of the contracting firm: Firm Ownership Type of Business NANDA Code Remarks: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR PERSON FILES AN APPLICATION CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME UNDER APPLICABLE LAW. THE APPLICANTS AND INDEMNITORS CERTIFY THE TRUTH OF ALL STATEMENTS IN THE APPLI- CATION AND AUTHORIZE THE GUARANTEE COMPANY OF NORTH AMERICA TO VERIFY THIS INFORMATION AND TO OBTAIN ADDITIONAL INFORMATION FROM ANY SOURCE INCLUDING OBTAINING A CREDIT REPORT. Completed by: Title: Date: 5 of 5 Excellence, Expertise, Experience... Every time theguaranteeus.com The Guarantee Company of North America. All rights reserved. The Guarantee is a trademark of The Guarantee Company of North America. Document contains general information and is not part of the policy. The terms of the insurance contract apply in all circumstances.
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**Email completed qualification form to subs@hammondconstruction.com Company Name: : Address: City: State: Zip: : Fax: Federal ID#: Email Address: Type of work qualified to perform: (masonry, steel, etc.)
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NATIONWIDE LIFE INSURANCE COMPANY NATIONAL CASUALTY COMPANY CLAIM FORM THIS CLAIM CANNOT BE PROCESSED WITHOUT ALL OF THE BELOW INFORMATION AND STATEMENTS OF PAYMENTS FROM THE OTHER PLANS. CLAIM FILING