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Great Neck, NY 11021
516-466-4200 (  HYPERLINK "http://www.butwin.com" www.butwin.com 

fax  516-466-4213   no cover page needed


or exit, save and e-mail to  HYPERLINK "mailto:allstate@butwin.com" allstate@butwin.com 

 HYPERLINK "http://www.butwin.com/" ARTISAN
CONTRACTORS APPLICATION

       Press TAB to move between fields
		
Applicants Name: FORMTEXT      DBA : FORMTEXT      Address: FORMTEXT      Agent FORMTEXT      City, State, Zip: FORMTEXT      Contact FORMTEXT       FORMTEXT County: FORMTEXT       FORMTEXT  FORMTEXT E-mail FORMTEXT       FORMTEXT  FORMTEXT Township: (State of PA only) FORMTEXT       FORMTEXT  FORMTEXT Phone FORMTEXT       FORMTEXT  FORMTEXT Contact & Phone: FORMTEXT  FORMTEXT      Fax FORMTEXT  FORMTEXT      E-mail & Website: FORMTEXT       FORMTEXT  FORMTEXT  FORMTEXT  FORMCHECKBOX  Individual         FORMCHECKBOX  Partnership         FORMCHECKBOX  Corporation         FORMCHECKBOX  Other:  FORMTEXT      Entity is in business for: FORMTEXT      Years  or   FORMCHECKBOX NewCoverage Effective Date: FORMTEXT       FORMTEXT Entity has prior liability insurance: FORMCHECKBOX Yes   FORMCHECKBOX No %  If yes,  FORMCHECKBOX 1yr    FORMCHECKBOX 2yrs    FORMCHECKBOX 3yrs % Any lapses during that time:   FORMCHECKBOX Yes   FORMCHECKBOX No    %  If yes, list most recent Insurance Carrier:  FORMTEXT  FORMTEXT      DESCRIBE ALL OPERATIONS:Type here... FORMTEXT       FORMTEXT     %Carpentry FORMTEXT     %Drywall FORMTEXT     %Electrical FORMTEXT     %Landscaping FORMTEXT     %Masonry FORMTEXT     %Painting FORMTEXT     %Plumbing FORMTEXT     %Woodworking           % (describe above) FORMTEXT     %Cabinet Making / Install FORMTEXT     %Door, Window, Partition Install / Repair FORMTEXT     %Other%  Commercial Work, in Offices  FORMTEXT     %        Any other Commercial Work  FORMTEXT     %        Residential Work  FORMTEXT     %%  Inside Buildings  FORMTEXT     %   vs.  Outside Buildings  FORMTEXT     %%  Other business  owned by applicant, including any unrelated operations:   FORMCHECKBOX  Yes    FORMCHECKBOX  No %  If yes, list: FORMTEXT       FORMTEXT %  More than 5% of work is performed outside of  HOME  state:   FORMCHECKBOX  Yes    FORMCHECKBOX  No % If yes, list other states:  FORMTEXT       FORMTEXT 
Any Work Involving:
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ALARMS
 FORMCHECKBOX  Yes   FORMCHECKBOX  No

ROOFING
 FORMCHECKBOX  Yes   FORMCHECKBOX  No 
FIRE SPRINKLERS
 FORMCHECKBOX  Yes   FORMCHECKBOX  No

      TREE PRUNING / SPRAYING
 FORMCHECKBOX  Yes   FORMCHECKBOX  No
SEWERS & DRAINS
 FORMCHECKBOX  Yes   FORMCHECKBOX  No

MEDICAL OR LIFE SUPPORT
 FORMCHECKBOX  Yes   FORMCHECKBOX  No
LAWN SPRINKLERS
 FORMCHECKBOX  Yes   FORMCHECKBOX  No

EXTERIOR WORK ABOVE 3 STORIES
 FORMCHECKBOX  Yes   FORMCHECKBOX  No
snow / ice removal
 FORMCHECKBOX  Yes   FORMCHECKBOX  No

HEATING / AIRCONDITIONING
 FORMCHECKBOX  Yes   FORMCHECKBOX  No
Backhoes
 FORMCHECKBOX  Yes   FORMCHECKBOX  No

BELOW GRADE WORK
 FORMCHECKBOX  Yes   FORMCHECKBOX  No % If yes, maximum depth:  FORMTEXT      



GENERAL LIABILITY      FORMCHECKBOX  $300,000       FORMCHECKBOX   FORMCHECKBOX  $500,000       FORMCHECKBOX  FORMCHECKBOX  $1,000,000       FORMCHECKBOX  FORMCHECKBOX  $2,000,000       FORMCHECKBOX   FORMCHECKBOX $3,000,000# OF Owners: FORMTEXT      Owners Annual Payroll or Draw:$  FORMTEXT      # of Full Time Employees (no owners or clerical): FORMTEXT      Annual Payroll (no owners or clerical):$  FORMTEXT       FORMTEXT # of Part Time Employees: FORMTEXT      Gross Receipts:$  FORMTEXT       FORMTEXT Does the insured hire subcontractors:  FORMCHECKBOX Yes    FORMCHECKBOX No % If  yes % cost of subcontractors:$  FORMTEXT      PROPERTY %  Coverage requested:   FORMCHECKBOX Yes    FORMCHECKBOX No  %  If yes, select coverage below:Building:$  FORMTEXT      Deductible:      FORMCHECKBOX  $250      FORMCHECKBOX  $500      FORMCHECKBOX  $1,000      FORMCHECKBOX  $2,500Business Contents:$  FORMTEXT      Off-Premises Property/Tool Floater:$  FORMTEXT          FORMTEXT    %   if Tools chosen, list total value  % over $700  $ FORMTEXT         % under $701  $ FORMTEXT       Customer s or other people s property held for service, storage or repair:   FORMCHECKBOX  Yes    FORMCHECKBOX  No

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