FORMS | Starlight Agency

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COMMERCIAL POLICY FORM

Company Name

Company Address

Email

Employer Identification Number

Company Opening Date

Owner's Name

Birth Date

Description of Services Offered

Maximum height of work (ft)

Employees’ Payroll (US$)

Owner’s Payroll (US$)

Percentage of Subcontracted Work (%)

How Many Employees

Gross Income (US$)

Should owner be included in the workers compensation?

YES

NO

Gross Amount Paid to Subcontractors (US$)

Description of Operation of Subcontractors

How Many Years of Experience

Percentage between residential and commercial jobs (%)

Percentage Between Interior (%)And Exterior Work

Percentage Between New Construction And Remodeling Work

Phone

If you do new construction, do you do town house, row house, apartment, or condo?

Town House

Row House

Apartment

Condo

Referring to the question above, what is the number of units in just one development?

10

15

20

25

Other

The company had insurance before? (Workers Compensation or General Liability)

YES

NO

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States of Operation

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