Home Office: Columbus, Ohio

Surety Administrative Office:

7 World Trade Center, 37th Floor

250 Greenwich Street

New York, NY 10007-0033

SUPPLEMENTAL CONTRACTOR QUESTIONNAIRE—NEW HAMPSHIRE

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 Accrual % of Completion

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

Name of your Bank:

Address:

Phone: Contact Person:

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

Are there any UCC Filings? Yes No How 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 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 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 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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