I. BUSINESS INFORMATION - PayneWest Insurance



I. BUSINESS INFORMATIONFirm Name: FORMTEXT ?????Contact Name: FORMTEXT ?????E-mail Address: FORMTEXT ?????Firm Address: FORMTEXT ????? FORMTEXT ?????Phone: FORMTEXT ?????Fax: FORMTEXT ?????Website: FORMTEXT ?????State of Incorporation: FORMTEXT ?????Year Started: FORMTEXT ????Tax ID: FORMTEXT ?????Is Your Firm Union? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX BothContracting Specialty: FORMTEXT ?????LEED Project Experience: FORMCHECKBOX YesNumber of Projects: FORMTEXT ???? FORMCHECKBOX NoNumber of LEED Certified Employees: FORMTEXT ????Geographic Area(s) of Operation (Territory): FORMTEXT ?????Type of Business: FORMCHECKBOX C-Corp. FORMCHECKBOX Sub S. Corp. FORMCHECKBOX Part. FORMCHECKBOX Sole Prop. FORMCHECKBOX LLC FORMCHECKBOX LLP# of Employees:Office: FORMTEXT ????Field (min): FORMTEXT ????to (max): FORMTEXT ????Current Total: FORMTEXT ????Affiliations: FORMCHECKBOX AGC FORMCHECKBOX ASA FORMCHECKBOX ABC FORMCHECKBOX CFMAOther: FORMTEXT ?????Certifications: FORMCHECKBOX 8a FORMCHECKBOX HubZone FORMCHECKBOX SDVOSBOther: FORMTEXT ?????II. OFFICER INFORMATIONList all owners, proprietors, partners, and officers of the firm:#1#2Full Legal Name: FORMTEXT ?????Full Legal Name: FORMTEXT ?????Date of Birth: FORMTEXT ?????% Owned: FORMTEXT ?????Date of Birth: FORMTEXT ?????% Owned: FORMTEXT ?????Social Security #: FORMTEXT ?????Social Security #: FORMTEXT ?????Position: FORMTEXT ?????Since: FORMTEXT ?????Position: FORMTEXT ?????Since: FORMTEXT ?????Home Address: FORMTEXT ?????Home Address: FORMTEXT ?????Spouse Legal Name: FORMTEXT ?????Spouse Legal Name: FORMTEXT ?????Spouse Date of Birth: FORMTEXT ?????Spouse Date of Birth: FORMTEXT ?????Spouse Social Security #: FORMTEXT ?????Spouse Social Security #: FORMTEXT ?????#3#4Full Legal Name: FORMTEXT ?????Full Legal Name: FORMTEXT ?????Date of Birth: FORMTEXT ?????% Owned: FORMTEXT ?????Date of Birth: FORMTEXT ?????% Owned: FORMTEXT ?????Social Security #: FORMTEXT ?????Social Security #: FORMTEXT ?????Position: FORMTEXT ?????Since: FORMTEXT ?????Position: FORMTEXT ?????Since: FORMTEXT ?????Home Address: FORMTEXT ?????Home Address: FORMTEXT ?????Spouse Legal Name: FORMTEXT ?????Spouse Legal Name: FORMTEXT ?????Spouse Date of Birth: FORMTEXT ?????Spouse Date of Birth: FORMTEXT ?????Spouse Social Security #: FORMTEXT ?????Spouse Social Security #: FORMTEXT ?????Will all owners and their spouses provide full personal indemnification to the surety? FORMCHECKBOX Yes FORMCHECKBOX No (explain below)Explanation: FORMTEXT ?????Is there a buy/sell agreement among the owners of the firm? FORMCHECKBOX Yes FORMCHECKBOX NoIs this agreement funded by life insurance? FORMCHECKBOX Yes FORMCHECKBOX NoIII. BUSINESS DETAILSHas your firm or any of its principals ever petitioned for bankruptcy, failed in business, failed to complete a contract, or caused a loss to a surety? If yes, please attach an explanation. FORMCHECKBOX Yes FORMCHECKBOX NoIs your firm or any of its owners or officers currently involved in any litigation? If yes, please attach an explanation. FORMCHECKBOX Yes FORMCHECKBOX NoPercentage of the firm’s work for:Government Owners: FORMTEXT ??? %Private Owners: FORMTEXT ??? %Other Contractors: FORMTEXT ??? %Trades you normally undertake with your own employees: FORMCHECKBOX None (Paper GC) FORMCHECKBOX FORMTEXT ?????Percentage of the firm’s work normally subcontracted to others: FORMTEXT ??? %Trades you normally subcontract: FORMTEXT ?????Sub bonding policy: FORMTEXT ?????Preferred job size range:$ FORMTEXT ?????to$ FORMTEXT ?????Number of jobs at a time: FORMTEXT ?????Largest cost to complete backlog:$ FORMTEXT ?????Year: FORMTEXT ?????Number of jobs: FORMTEXT ?????Largest job expected during the next year: FORMTEXT ?????Largest backlog expected during the next year: FORMTEXT ?????Expected annual volume this current fiscal year: FORMTEXT ?????Next fiscal year: FORMTEXT ?????Do you lease equipment? FORMCHECKBOX Yes FORMCHECKBOX NoType of lease: FORMTEXT ?????Terms of the lease: FORMTEXT ?????IV. FINANCIAL INFORMATIONName of CPA Firm: FORMTEXT ?????Fiscal Year End: FORMTEXT ?????Contact Name: FORMTEXT ?????E-mail: FORMTEXT ?????Company Address: FORMTEXT ?????Company Phone: FORMTEXT ?????Fax: FORMTEXT ????? Web Site: FORMTEXT ?????On what basis are taxes paid? FORMCHECKBOX Cash FORMCHECKBOX Completed Job FORMCHECKBOX Accrual FORMCHECKBOX % of CompletionOn what basis are financial statements prepared? FORMCHECKBOX Cash FORMCHECKBOX Completed Job FORMCHECKBOX Accrual FORMCHECKBOX % of CompletionOn what level of assurance are financial statements prepared? FORMCHECKBOX CPA Audit FORMCHECKBOX Review FORMCHECKBOX CompilationHow often are internal financial statements prepared? FORMCHECKBOX Annually FORMCHECKBOX Semi-Annually FORMCHECKBOX Quarterly FORMCHECKBOX MonthlyHow are bills paid? FORMCHECKBOX Discounts taken as offered FORMCHECKBOX Prompt within payment terms FORMCHECKBOX Late, within FORMTEXT ???days of dueAny material troubled A/R? FORMCHECKBOX No FORMCHECKBOX YesExplain: FORMTEXT ?????Changes to the balance sheet since last fiscal year end (contributions, distributions, loans, material asset buys or sells, financing, etc.): FORMTEXT ?????Do you have a full-time accountant on staff? FORMCHECKBOX Yes FORMCHECKBOX NoName: FORMTEXT ?????Staff accountant professional designations: FORMCHECKBOX CPA FORMCHECKBOX CCIFP FORMCHECKBOX Other: FORMTEXT ?????Accounting Software: FORMTEXT ?????Estimating Software: FORMTEXT ?????Job Cost Software: FORMTEXT ?????V. BANK INFORMATIONName of Bank: FORMTEXT ?????Address: FORMTEXT ?????Contact Name: FORMTEXT ?????Phone: FORMTEXT ?????E-mail: FORMTEXT ?????With this Bank Since: FORMTEXT ????Relationship currently includes: FORMCHECKBOX Deposit accounts FORMCHECKBOX Revolving line of credit FORMCHECKBOX Term loansLine of Credit (LOC) Year Opened: FORMTEXT ????Amount:$ FORMTEXT ?????Line Expires: FORMTEXT ?????LOC – FORMCHECKBOX Unsecured FORMCHECKBOX Secured By: FORMTEXT ?????LOC – Special Terms or Sublimits: FORMTEXT ?????Other Bank(s) Used and Purpose: FORMTEXT ?????VI. EXPERIENCE & REFERENCESPrevious Bonding Companies:Name:Dates:Reason for leaving:1 FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????2 FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????3 FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Have you ever been turned down by a surety? FORMCHECKBOX Yes FORMCHECKBOX No If yes, why? FORMTEXT ?????Largest Completed Contracts (largest first):Job Name: FORMTEXT ?????Job Name: FORMTEXT ?????City, State: FORMTEXT ?????City, State: FORMTEXT ?????Contract Price: FORMTEXT ?????Contract Price: FORMTEXT ?????Gross Profit: FORMTEXT ?????Gross Profit: FORMTEXT ?????Date Completed: FORMTEXT ?????Date Completed: FORMTEXT ?????Bonded?:Yes FORMCHECKBOX No FORMCHECKBOX Bonded?:Yes FORMCHECKBOX No FORMCHECKBOX Contract Name: FORMTEXT ?????Contract Name: FORMTEXT ?????Firm: FORMTEXT ?????Firm: FORMTEXT ?????Phone: FORMTEXT ?????Fax: FORMTEXT ?????Phone: FORMTEXT ?????Fax: FORMTEXT ?????E-Mail: FORMTEXT ?????E-Mail: FORMTEXT ?????Project Description: FORMTEXT ?????Project Description: FORMTEXT ?????Job Name: FORMTEXT ?????Job Name: FORMTEXT ?????City, State: FORMTEXT ?????City, State: FORMTEXT ?????Contract Price: FORMTEXT ?????Contract Price: FORMTEXT ?????Gross Profit: FORMTEXT ?????Gross Profit: FORMTEXT ?????Date Completed: FORMTEXT ?????Date Completed: FORMTEXT ?????Bonded?:Yes FORMCHECKBOX No FORMCHECKBOX Bonded?:Yes FORMCHECKBOX No FORMCHECKBOX Contract Name: FORMTEXT ?????Contract Name: FORMTEXT ?????Firm: FORMTEXT ?????Firm: FORMTEXT ?????Phone: FORMTEXT ?????Fax: FORMTEXT ?????Phone: FORMTEXT ?????Fax: FORMTEXT ?????E-Mail: FORMTEXT ?????E-Mail: FORMTEXT ?????Project Description: FORMTEXT ?????Project Description: FORMTEXT ?????Job Name: FORMTEXT ?????Job Name: FORMTEXT ?????City, State: FORMTEXT ?????City, State: FORMTEXT ?????Contract Price: FORMTEXT ?????Contract Price: FORMTEXT ?????Gross Profit: FORMTEXT ?????Gross Profit: FORMTEXT ?????Date Completed: FORMTEXT ?????Date Completed: FORMTEXT ?????Bonded?: Yes FORMCHECKBOX No FORMCHECKBOX Bonded?:Yes FORMCHECKBOX No FORMCHECKBOX Contract Name: FORMTEXT ?????Contract Name: FORMTEXT ?????Firm: FORMTEXT ?????Firm: FORMTEXT ?????Phone: FORMTEXT ?????Fax: FORMTEXT ?????Phone: FORMTEXT ?????Fax: FORMTEXT ?????E-Mail: FORMTEXT ?????E-Mail: FORMTEXT ?????Project Description: FORMTEXT ?????Project Description: FORMTEXT ?????Major Suppliers (largest volume first):Name:Products:Phone:Fax:Contact name:Last used:1 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????2 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????3 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????4 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????5 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Major Trade Subcontractors, or Contractors If You Are a Trade Contractor (largest volume first):Name:Trade:Phone:Fax:Contact name:Last used:1 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????2 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????3 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????4 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????5 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Specialty Trade Subcontractors:Name:Trade:Phone:Fax:Contact name:Last used:1 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????2 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????3 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????III. KEY PERSONNELAdditional Key Personnel:Name:Designation(s):Position:Birth Year:Years Experience Total YearsAt This Company:Experience:1 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ???? FORMTEXT ?? FORMTEXT ??2 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ???? FORMTEXT ?? FORMTEXT ??3 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ???? FORMTEXT ?? FORMTEXT ??4 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ???? FORMTEXT ?? FORMTEXT ??5 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ???? FORMTEXT ?? FORMTEXT ??IX. LIFE INSURANCE INFORMATIONLife Insurance in Effect on Officers or Key Personnel:Insured:Beneficiary:Death Benefit:Insurance Company:1 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????2 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????3 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????4 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????X. BUSINESS INSURANCE INFORMATIONStaff Risk Manager: FORMTEXT ?????Designations: FORMCHECKBOX AFSB FORMCHECKBOX CPCU FORMCHECKBOX CRIS FORMCHECKBOX Other: FORMTEXT ?????Insurance Broker/Agency: FORMTEXT ?????City/ State: FORMTEXT ?????Agent’s Name: FORMTEXT ?????E-mail: FORMTEXT ?????Phone: FORMTEXT ?????Fax: FORMTEXT ?????Key Expiration Dates: FORMTEXT ?????XI. SUBSIDIARIES AND AFFILIATESSubsidiaries and Affiliates of the Applicant Firm:Firm name:Ownership/Relationship:Type of Business:FEIN:Cross/Corp.Indemnity?1 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No2 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No3 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No4 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No5 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoRemarks: FORMTEXT ?????XII. ATTACHMENTS FORMCHECKBOX Copies of the last three fiscal year-end financial statements including work in progress and completed contract schedules. FORMCHECKBOX Current interim financial statement and work in progress report if fiscal statement is over six months old. FORMCHECKBOX Current personal financial statement for all indemnitors. FORMCHECKBOX Bank Line of Credit Agreement. FORMCHECKBOX Business Plan. FORMCHECKBOX Federal Tax Returns. FORMCHECKBOX Company – years: FORMTEXT ????? FORMCHECKBOX Personal – years: FORMTEXT ????? FORMCHECKBOX Buy / Sell Agreement. FORMCHECKBOX Specimen copy of Subcontract Agreement. FORMCHECKBOX Certificate(s) of Insurance (all lines carried). FORMCHECKBOX Resumes of owners / key employees. FORMCHECKBOX Brochure and/or Letters of Recommendation about the accomplishments of your firm. FORMCHECKBOX Other: please describe below under “Additional Remarks.”Applicant(s) hereby authorize the Surety Company and the Agency to make such pertinent inquiry as may be necessary from business and personal credit reporting agencies, financial institutions, persons, firms, and corporations in order to confirm and verify information referred to or listed on this application.This questionnaire must be signed by an owner or officer of the company for which bonding is being requested.Name of Firm: FORMTEXT ?????Completed By: FORMTEXT ?????Title: FORMTEXT ?????Signature:Date: FORMTEXT ?????Additional Remarks: FORMTEXT ????? ................
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