Business Name *

Business Phone Number *

Years of Experience *

Years in Business *

Website

Description of day-to-day operations *

I HOLD, OR HAVE HELD, THE FOLLOWING LICENSES:

License#1 *

License Held#1
State Issued#1
Date Issued#1
Expiration Date#1

License#2

License Held#2
State Issued#2
Date Issued#2
Expiration Date#2

LARGEST JOB IN THE LAST 5 YEARS *

1:- Company
2:- Description of Duties
3:- Start Date
4:- End Date
5:- Cost/$

BREAKDOWN OF WORK IN % *

1:- Residential %
2:- Commercial %
3:- New %
4:- Remodel %
5:- Subcontracted/1099s%
6:- Subcontractor Cost/$

Any hazardous work subcontracted out? (I.e. mold, asbestos, medical waste, etc.) *

If, YES please explain..

What is the minimum GL limit required? *

Do you require subcontractors to name you as additional insured? *

Does your contract with your subcontractor include a hold harmless agreement in your favor? *

Any work for condo or townhouse associations or tract homes? *

Gross Receipts *

$

Owner/Officer Payrolls *

$

Have you filed any lawsuits against any customer in the last 4 years for non-payment of your services? *

Has a lawsuit been filed against your company and liability was assumed? *

Do you perform any OCIP/Wrap up work? *

List the states you operate in: *

Have you ever had prior GL coverage? *

Yes

No

If Yes, Please request and submit loss run report to Team@litespeedins.com and also please fill out the last 3 years loss details below:

Last 3 Year Loss Summary.. (Please fill the details to the best of your knowledge)

a:- Year
b:- Carrier
c:- Premium
d:- Claims
e:- Incurred
f:- Comments

If No, please sign the STATEMENT OF NO LOSS
below:

I CERTIFY THAT I AM NOT AWARE OF ANY LOSSES, ACCIDENTS OR CIRCUMSTANCES THAT MIGHT GIVE RISE TO A CLAIM UNDER THE INSURANCE POLICY :

Clear

Signature

Signing Dates

From Last 5 Year

To

Date and Time Signed

Types and percentages of roofing operations performed by applicant or subcontractors Include all that apply - state 'none' if none or not applicable - DO NOT LEAVE BLANK:

% of Total Annual Gross Receipts of System Type *

1:- Asphalt Shingles
2:- Any operation of any type involving hot tar or torch
3:- Clay or Concrete Tile
4:- Metal Roof Systems for steep slope applications
5:- Slate
6:- Treated Wood Shakes or Shingles
7:- Other Synthetic Coverings
8:- Built Up Roof Systems – “Tar and Gravel”
9:- Built Up Roof Systems Polymer-Modified bitumen sheet membranes
10:- Metal panel roof systems for low-slope applications
11:- Single-ply membranes
12:- Thermoplastic membranes
13:- Thermoset membranes
14:- Spray polyurethane foam-based
15:- “Green Roof” Systems (Designed to allow planting/landscaping on roof)
16:- Other (Please Describe)

Type and Percentage of Roofing Work done by the applicant or subcontractors Include all that apply - state 'none' if none or not applicable - DO NOT LEAVE BLANK:

% of Annual Gross Receipts of Type of Roofing Work *

1:- Residential – Repair, Remodel, or Re-roof of Individual Dwelling
2:- Residential – Repair, Remodel, or Re-roof of Multi-family Dwellings
3:- Residential – Repair, Remodel, or Re-roof of Apartments
4:- Residential – Additions onto Individual Dwellings
5:- Residential – Additions onto Condos, Apartments, or Townhome
6:- Residential – New Construction – Condos, Apartments, Townhomes
7:- Residential – New Construction - Individual Single - Family Dwellings
8:- Residential – New Construction - Tract or Subdivision Dwellings
9:- Commercial – Repair, Remodel, or Re-roof
10:- Commercial – New Construction
11:- Industrial – New Construction or Repair
12:- Other (Please describe)

Years in business under this name. *

Years of owner/management experience in roofing field. *

Roofing Contractor’s License Number. *

Are you a member of NRCA (National Roofing Contractors Association)? *

Yes

No

Have you operated under any other name during last 5 years? *

Yes

No

If yes, provide all prior names and describe operations. *

States/Area of operations *

Number of Employees *

Total Annual Gross Sales/Receipts *

$

CLASSIFICATION OF OPERATIONS (PAYROLL/SUB-COSTS)

Employee Payroll/$ for each type of construction work performed.

1:- Roofing – Residential
2:- Roofing – Commercial
3:- Carpentry (Other than involved directly with roofing)
4:- Gutter Installation, Repair or Replacement
5:- Solar Panel or other Solar Energy Work
6:- Waterproofing work
7:- Insulation Work
8:- Other (Please describe)

Sub-Contractor Cost/$ for each type of construction work performed.

a:- Roofing – Residential
b:- Roofing – Commercial
c:- Carpentry (Other than involved directly with roofing)
d:- Gutter Installation, Repair or Replacement
e:- Solar Panel or other Solar Energy Work
f:- Waterproofing work
g:- Insulation Work
h:- Other (Please describe)

Describe in detail specific procedures in place to prevent 'open roof' damage in event of rain or other inclement weather. *

What specific methods are used to monitor incoming weather at each job site during progress of job (BE SPECIFIC)? *

What specific criteria are used to determine when roof should be secured and covered due to oncoming weather (BE SPECIFIC) *

What employee at each job site is responsible for determining when and how to cover roof in event of oncoming weather (BE SPECIFIC)? *

PROJECTS/OPERATIONS INFORMATION

Past 5 Completed Projects
(Mandatory)

PROJECT#1 *

1#Project Name
1#State
1#Project Description
1#Roofing System Type
1#Dates
1#Cost/$

PROJECT#2 *

2#Project Name
2#State
2#Project Description
2#Roofing System Type
2#Dates
2#Cost/$

PROJECT#3 *

3#Project Name
3#State
3#Project Description
3#Roofing System Type
3#Dates
3#Cost/$

PROJECT#4

4#Project Name
4#State
4#Project Description
4#Roofing System Type
4#Dates
4#Cost/$

PROJECT#5

5#Project Name
5#State
5#Project Description
5#Roofing System Type
5#Dates
5#Cost/$

Any Current and Planned/Future Projects (Mandatory)

Current and Planned/Future Projects

1:- Project Name
2:- State
3:- Project Description
4:- Roofing System Type
5:- Dates
6:- Cost/$

Any exterior work performed above three stories in height from grade? *

Yes

No

Any work done using untreated wood shingles? *

Yes

No

OTHER INSURANCE

Do you currently have Workers Compensation coverage in place? *

Yes

No

Any other operation(s) in addition to those which are shown in this application? *

Yes

No

Any other operation(s) in addition to those which are shown in this application? If yes, please describe. *

Where is the General Liability for this operation insured? *