Bozzuto & Assocaites Insurance Agency Inc.

3425 S Bascom Ave #100

Campbell CA 95008

Owner Name:______Business Name:______

Mailing Address:______City______State____Zip______

Years In Business: ______Years Experience: ______Contractors Class & Number: ______

Street Address( if different from mailing)______City______St___ Zip______Phone ( )______Fax ( )______

Business: ______Corporation ______Partnership ______Sole Ownership

Detailed Description of Operations:______

______

______

______
______

Gross Receipts: Last 3 yrs : 20( ) ______20( ) ______20( ) ______

Estimated Receipts for this year: ______

Payroll for past 3 yrs excluding clerical & owners 20( )______20 ( ) ______20______

Estimated Payroll for this year: ______

Number of: Owner/Partner List only those active in the field:______

Amount Sub contracted work for last year: ______

Estimated Sub-cost this year: ______

Type and % of Subcontractors used:

______%______%______%______%

______%______% ______%______%

Do you collect certificates from all of the subcontractors used:______if yes at what limits do you require?______

Do you have all subs name you as Additional Insured on the certificates you receive?______

Indicate percent of work you perform:

______% New ground up residential ______% Repair/Remodel Residential ______% Structural Repair- Residential ______% Non structural repair-Residential .______% New Commercial ______% Repair/Remodel Commercial ______% Industrial ______% Apartment/Condo Work ______% Maintenance %______Tract Homes, Y __ N__ Size of Tracts______

If you are doing tract housing (if yes maximum number of homes in tract______) apartment/condo work please describe work performed: ______

Do you perform work above two stories in height (other than interior remodeling)? ______If yes, what percentage?

______How high?______Please describe______

Do you now or have you ever performed work on hillsides, slopes, or landfills?______If yes include degree of slope?______If yes also please describe?______

Type of Work that you perform: (Total % must equal 100)

____% Carpentry Interior / ___%Debris Removal / ____% Janitorial / ____% Plumbing / ____% Other______
____% Carpentry Resid. / ___%Electrical within
Buildings / ____% Landscape
Gardening / ____% New Roof / ____% Other______
____% Carpentry NOC / ___% Excavation / ____% Landscape
Design / ____% Reroof
____% Concrete / ___% Grading / ____% Landscape
Maintenance / ____% Waterproofing
____% Drywall/Wallboard / ___% Insulation / ____% Painting / ____% Welding

What is the dollar amount on average per job (including all materials, labor, & equipment)?______

General Contracting please complete the following:

How many new structures do you build in one year?______Greatest number you have built in one year:______

Percent of Work Performed as : ______% General Contractor ______% Sub contractor

Excavation/Grading please complete the following:

Do you perform any work below ground level?______If yes what %______What is the Max. depth_____ft

Please describe jobs :______

______

Grading: Do you perform any work for airports?______

Please describe various jobs:______

______

Please describe three of your largest projects over the last 5 years (include material and sub cost):

1.______

2.______

3.______

Please describe two of your upcoming projects for this policy year:

1.______

2.______

Have you or will you perform or sub contract any of the following: construction management for a fee, demolition of an entire structure, tilt-up concrete, LPG work, earthquake retro fitting or updating, swimming pool construction, shoring, construction of roads, parking structures, underground tank removal or installation, asbestos abatement, or other pollution clean up?

______If yes please describe______

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General Liability Limits Requested: per aggregate______per occurrence______

Expiration date of current policy:______

List and describe any and all claims in the past five years (including amount paid):

______

Property Coverage:

Building (if owned)$______

Business Personal Property$______

Computer Equipment$______

Business Interruption$______

Inland Marine/Scheduled Equipment$______

Miscellaneous Unscheduled Equipment/Small Tool$______

Umbrella/Excess Liability Limit$______

Vehicle Schedule: ( please provide vehicle with VIN #, GVW, if physical damage is required provide cost new

and a separate value of permanently attached customized, altered or special equipment that you want covered)

Driver Schedule: ( please include all drivers license numbers and full name)