Home Office: Scottsdale, Arizona
Surety Administrative Office:
7 World Trade Center, 37th Floor
250 Greenwich Street
New York, NY 10007-0033

CONTRACTOR QUESTIONNAIRE—NEW HAMPSHIRE

Name of Company:

Address:

(street) (city) (state) (zip)

Phone: Contact Person (Name & Title):

Federal Tax ID Number: Year Business Started:

State of Incorporation: Type of Business: Corp. Part. Prop. Sub. S. Corp. L.L.C.

Area of Operation: Contracting Specialty:

List the corporate officers, partners or proprietors of your firm:

Name / Position / Percent Owned / Social Security No. / Year of Birth / Name of Spouse / Social Security No.

Is Indemnity of the following available:

Personal? Yes No

Spousal? Yes No

Corporate? Yes No

Cross Corporate of a Related Company? Yes No

If you answered “No” to any of the above, please explain:

Is there a buy/sell agreement among the owners of the business? Yes No

Is there a key person agreement in place? Yes No

Is either of the two above agreements funded by life insurance? Yes No

Has your firm or any of its principals ever:

Petitioned for Bankruptcy? Yes No

Defaulted on a contract? Yes No

Failed in Business? Yes No

Caused a loss to a surety? Yes No

If you answered “Yes” to any of the above, please explain:

Is your firm or any of its owners or officers currently involved in any litigation? Yes No

If you answered “Yes,” please explain:

How many people does your firm employ? How many work crews?

Is your firm unionized? Yes No

What percentage of the firm’s work is normally for: Government Agencies: % Private Owners: %

SIC CODE: What trades do you normally undertake with your own forces?

What percentage of the firm’s work is normally subcontracted: %

Are bonds required of subcontractors? Yes No

What trades do you normally subcontract?

What was the largest amount of uncompleted work on hand at one time in the past? $ Year:

What is the largest job you expect to do during the next year? $

What is the largest uncompleted work program expected during the next year? $

What is your expected annual volume next year? $

Are job cost records kept? Yes No

Do they show job detail? Yes No

How often are they reviewed? How often are they updated?

Do you lease equipment? Yes No

What is the type of lease and what are the terms?


Name of your CPA:

Address:

Phone: Contact Person:

Do you have a full time accountant on staff? Yes No Years of Experience:

Corporate fiscal year end date:

How often are financial statements prepared? Annually Semi-annually Quarterly Monthly

On what level of quality are financial statements prepared? CPA Audit Review Compilation

On what basis are financial statements prepared? Cash Completed Job Accrual % of Completion

On what basis are taxes paid? Cash Completed Job Accrual % of Completion

Name of your Bank:

Address:

Phone: Contact Person:

Type of Account: Acct. Number:

Amount of line of credit: $ Expiration Date: What is the interest rate? %

Are there any UCC Filings? Yes No How is credit secured?

What is the firm’s Dun & Bradstreet Number? D&B Rating: Date of Rating: Paydex Score:

Remarks:

Previous Bonding Companies (list most current first):

Company Name / Reason For Leaving

List five of your largest contracts:

Owner Name & Job Description / Contract Price / Gross Profit / Completion Date
Contact Name / Contact Number / Bonded Yes/No
Owner Name & Job Description / Contract Price / Gross Profit / Completion Date
Contact Name / Contact Number / Bonded Yes/No
Owner Name & Job Description / Contract Price / Gross Profit / Completion Date
Contact Name / Contact Number / Bonded Yes/No
Owner Name & Job Description / Contract Price / Gross Profit / Completion Date
Contact Name / Contact Number / Bonded Yes/No
Owner Name & Job Description / Contract Price / Gross Profit / Completion Date
Contact Name / Contact Number / Bonded Yes/No

List five of your major suppliers:

Supplier Name & Address / Contact Name / Contact E-mail Address
Contact Phone Number / Contact Fax Number
Supplier Name & Address / Contact Name / Contact E-mail Address
Contact Phone Number / Contact Fax Number
Supplier Name & Address / Contact Name / Contact E-mail Address
Contact Phone Number / Contact Fax Number
Supplier Name & Address / Contact Name / Contact E-mail Address
Contact Phone Number / Contact Fax Number
Supplier Name & Address / Contact Name / Contact E-mail Address
Contact Phone Number / Contact Fax Number

List five subcontractors (or contractors if you are a subcontractor) that you do business with:

Name & Address / Contact Name / Contact Number
Job Name
Name & Address / Contact Name / Contact Number
Job Name
Name & Address / Contact Name / Contact Number
Job Name
Name & Address / Contact Name / Contact Number
Job Name
Name & Address / Contact Name / Contact Number
Job Name

List three Architects you have done business with:

Name & Address / Contact Name / Contact Number
Job Name
Name & Address / Contact Name / Contact Number
Job Name
Name & Address / Contact Name / Contact Number
Job Name

List key personnel, foremen or supervisors:

Name / Position / Year of Birth / Years of Experience / Previous Employer

List any life insurance in effect on key personnel:

Name / Company / Beneficiary / Amount / Cash Value

List other insurance coverage currently in effect or attach a Certificate of Insurance:

Coverage Type / BI / PD / Carrier / Expiration Date
General Liability
Auto Liability
Umbrella Liability
Workers’ Compensation

List any subsidiaries and affiliates of the contracting firm:

Company Name / Ownership / Type of Business


The undersigned hereby authorizes and requests any or all depositories or banks in which any funds of the undersigned may be deposited or from which moneys may be borrowed to advise the Company whenever requested, the amount of such deposits and or loans; and any depository bank, material man, supply house, or other person, firm, or corporation is hereby authorized to furnish to the Company any information requested concerning any transaction with the undersigned; and copies of the foregoing statement and any information which it now has, or may hereafter obtain, may be fur-nished to other companies for the purpose of securing reinsurance or co-insurance by the Company. This Contractor Questionnaire must be signed by the applicant.

NOTICE TO APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM 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 AND SUBJECTS THE PERSON TO CRIMINAL PENALTIES.

Signed and sealed this day of , .

(Principal Signature) (Seal)

PRODUCED BY (Insurance Agent or Broker):
Producer Name: Firm Name:
Taxpayer ID or Social Security No.: Producer’s License No.:
Agency:
Address (No., Street, City, State and Zip):

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