Home Office: Scottsdale, Arizona

Surety Administrative Office:

7 World Trade Center, 37th Floor

250 Greenwich Street

New York, NY 10007-0033

Supplemental Contractor Questionnaire - Maryland

Name of Company:

Address:

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

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 there a formal continuity plan in place?...... Yes No

If “Yes,” is it funded by Life Insurance?...... Yes No

List any subsidiaries and affiliates of the contracting firm:

Company Name / Ownership / Type of Business

Name of your CPA:

Address:

Phone: Contact Person:

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

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

Name of your Bank:

Address:

Phone: Contact Person:

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

Are there any UCC Filings?...... Yes NoHow is credit secured?

List three of your largest contracts most recently completed:

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 three of your current 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

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

The undersigned hereby authorizes and requests any or all depositories or banks in which any funds of the under-signed 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 here-after obtain, may be furnished to other companies for the purpose of securing reinsurance or co-insurance by the Company.This Supplemental Contractor Questionnaire must be signed by the applicant.

NOTICE TO APPLICANTS: Any person who knowinglyor willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false informationin an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Signed and sealed this day of , .

(Principal Signature)(Seal)

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