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DOES BUTWIN HAVE A MARKET FOR THIS PROSPECT?ARTISAN
CONTRACTORS APPLICATION
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Applicants Name: FORMTEXT D B A : F O R M T E X T A d d r e s s : F O R M T E X T A g e n t F O R M T E X T C i t y , S t a t e , Z i p : F O R M T E X T C o n t a c t F O R M T E X T F O R M T E X T C o u n t y : F O R M T E X T F O R M T E X T F O R M T E X T E - m a i l F O R M T E X T F O R M T E X T F O R M T E X T T o w n s h i p : ( S t a t e o f P A o n l y ) F O R M T E X T F O R M T E X T F O R M T E X T P h o n e F O R M T E X T F O R M T E X T F O R M T E X T C o n t a c t & P h o n e : F O R M T E X T F O R M T E X T F a x F O R M T E X T F O R M T E X T E - m a i l & W e b s i t e : F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M C H E C K B O X I n d i v i d u a l F O R M C H E C K B O X P a r t n e r s h i p F O R M C H E C K B O X C o r p o r a t i o n F O R M C H E C K B O X L L C F O R M C H E C K B O X O t h e r : F O R M T E X T E n t i t y i s i n b u s i n e s s f o r : F O R M T E X T Y e a r s o r F O R M C H E C K B O X N e w % # F O R M T E X T Y r s E x p e r i e n c e C o v e r a g e E f f e c t i v e D a t e : F O R M T E X T F O R M T E X T E n t i t y h a s p r i o r l i a b i l i t y i n s u r a n c e : F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o % I f y e s , F O R M C H E C K B O X 1 y r F O R M C H E C K B O X 2 y r s F O R M C H E C K B O X 3 y r s % A n y l a p s e s d u r i n g t h a t t i m e ? F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o D o w e h a v e c o p y o f c u r r e n t p o l i c y ? F O R M C H E C K B O X Y e s ( s u b m i t w i t h a p p ) F O R M C H E C K B O X N o % C a r r i e r : F O R M T E X T F O R M T E X T E x p i r i n g P r e m i u m : $ F O R M T E X T D E S C R I B E A L L O P E R A T I O N S : T y p e h e r e . . . F O R M T E X T F O R M T E X T % A i r C o n d i t i o n i n g F O R M T E X T % C a b i n e t M a k i n g / I n s t a l l a t i o n F O R M T E X T % C a r p e n t r y F O R M T E X T % D o o r / W i n d o w I n s t a l l / R e p a i r F O R M T E X T % D r i v e w a y P a v i n g F O R M T E X T % D r y w a l l F O R M T E X T % E l e c t r i c a l F O R M T E X T % F l o o r i n g F O R M T E X T % H e a t i n g F O R M T E X T % J a n i t o r i a l F O R M T E X T % L a n d s c a p i n g F O R M T E X T % L a w n S p r i n k l e r s F O R M T E X T % M a s o n r y F O R M T E X T % P a i n t i n g F O R M T E X T % P l u m b i n g F O R M T E X T % R o o f i n g F O R M T E X T % T i l e W o r k F O R M T E X T % W o o d w o r k i n g F O R M T E X T % O t h e r : F O R M T E X T % C o m m e r c i a l W o r k i n O f f i c e s F O R M T E X T % A n y o t h e r C o m m e r c i a l W o r k F O R M T E X T % R e s i d e n t i a l W o r k F O R M T E X T % % O t h e r b u s i n e s s o w n e d b y a p p l i c a n t , i n c l u d i n g a n y u n r e l a t e d o p e r a t i o n s : F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o % I f y e s , l i s t : F O R M T E X T F O R M T E X T % M o r e t h a n 5 % o f w o r k i s p e r f o r m e d o u t s i d e o f H O M E s t a t e : F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o % I f y e s , l i s t o t h e r s t a t e s : F O R M T E X T F O R M T E X T
Any Work Involving:
Cranes
FORMCHECKBOX Yes FORMCHECKBOX No
SNOW / ICE REMOVAL
FORMCHECKBOX Yes FORMCHECKBOX No
MEDICAL OR LIFE SUPPORT
FORMCHECKBOX Yes FORMCHECKBOX No
EXTERIOR WORK ABOVE 3 STORIES
FORMCHECKBOX Yes FORMCHECKBOX No
GENERAL LIABILITY FORMCHECKBOX $300,000 FORMCHECKBOX FORMCHECKBOX $500,000 FORMCHECKBOX FORMCHECKBOX $1,000,000 FORMCHECKBOX FORMCHECKBOX $2,000,000 FORMCHECKBOX FO R M C H E C K B O X $ 3 , 0 0 0 , 0 0 0 # O F O w n e r s : F O R M T E X T O w n e r s A n n u a l P a y r o l l o r D r a w : $ F O R M T E X T # o f F u l l T i m e E m p l o y e e s ( n o o w n e r s o r c l e r i c a l ) : F O R M T E X T A n n u a l P a y r o l l ( n o o w n e r s o r c l e r i c a l ) : $ F O R M T E X T F O R M T E X T # o f P a r t T i m e E m p l o y e e s : F O R M T E X T G r o s s R e c e i p t s : $ F O R M T E X T F O R M T E X T D o e s t h e i n s u r e d h i r e s u b c o n t r a c t o r s : F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o % I f y e s % c o s t o f s u b c o n t r a c t o r s : $ F O R M T E X T P R O P E R T Y % C o v e r a g e r e q u e s t e d : F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o % I f y e s , s e l e c t c o v e r a g e b e l o w : B u i l d i n g : $ F O R M T E X T D e d u c t i b l e : F O R M C H E C K B O X $ 2 5 0 F O R M C H E C K B O X $ 5 0 0 F O R M C H E C K B O X $ 1 , 0 0 0 F O R M C H E C K B O X $ 2 , 5 0 0 B u s i n e s s C o n t e n t s : $ F O R M T E X T O f f - P r e m i s e s P r o p e r t y / T o o l F l o a t e r : $ F O R M T E X T F O R M T E X T % i f T o o l s c h o s e n , l i s t t o t a l v a l u e : o v e r $ 7 0 0 $ F O R M T E X T u n d e r $ 7 0 1 $ F O R M T E X T C u s t o m e r s o r o t h er peoples property held for service, storage or repair: FORMCHECKBOX Yes FORMCHECKBOX No
Continued on next page
Butwin Insurance Group 516-466-4200 ( HYPERLINK "../index.htm"www.butwin.comARTISAN CONTRACTORS APPLICATION Page 2 of 2
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