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Contact Information

First name:

Last name:

Business Name:

Mailing Address:

Email Address:

Telephone Number:

Fax Number:

Business Information

Type of operation:

Describe operations in detail:

License class:

License Number:

Limit of Liability Coverage Requested?

$300000

$500000

$1 Million

Currently Insured?

Yes

Name of Carrier:

How long insured? (years)

Prior Claims?

Yes (if yes describe below)

Describe claims in detail:

Years in business:

Years experience in field:

Percentage of work residential:

Percentage of work commercial:

Number of Active Owners:

Number of Employees:

Annual Employee Payroll: $

Annual Gross Sales: $

Do you subcontract work?

Yes

(If yes what percentage of your work is subbed and what kind of work?)

Do you do foundation work?

Yes

Do you work on condos?

Yes

Do you have a safety program?

Yes

Comments or Questions:

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Hartman Insurance Solutions
13636 Ventura Blvd., Suite 484
Sherman Oaks, CA 91423

Phone: 866-333-8647
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