General Liability Contractors Supplemental Account Name in Business Under this Effective Date Years of Experience in this Field: Name: Type of License: Year Issued: #: Has the applicant ever operated any other name? If so, state the reason for the name change. Indicate type of work performed by the insured and subcontractors: (total should equal 100%) Subs Insured Subs Subs Levee % % Asbestos Abatement Sewers % % % % Work % % % Blasting Sheet Metal % % % % % % Bridge Building Masonry Sheet (Ornamental) % % % % % % Carpentry Mechanical Soil Stabilization % % % Mold % % % Concrete Street/Road Construction % % % % % % Drilling Painting Structural Demolition % % % % % % Electrical Pile Driving Supervisory Only % % % % % % Excavation Plastering Tunneling % % % % % % Fire Restoration Plumbing Underpinning Work % % % Pollution Gas Wrecking/Demolition % % % % % Abatement % % % % Insulation Roofing Restoration Work % % % Other Services % (specify) % Indicate the percentage of work performed by the applicant: % PERCENTAGE OF OPERATIONS COMMERCIAL RESIDENTIAL Total Annual Revenue Total Annual Revenue $ $ General Contractor % New Construction % New Construction % Subcontractor % Remodeling % Remodeling % Construction Manager % Other % % number of employees (including owner and all leased employees): Total - Full Time Part Time Estimate for Next 12 2016 2015 2014 2013 Months Annual Receipts Employee Payroll Exec. Supervisor Payroll Cost of Subcontracted Work List all states in which the applicant has done business in the past and will do business in the coming year? What percentage of work is performed outside of the home state? Does the applicant always require subcontractors to: insurance for General Liability and Worker’s Compensation? Yes No Carry insurance for Business Automobile? Yes No If yes, list limits: Require equal limits in General Liability coverage? Yes No Name the applicant as an additional insured on all policies? Yes No Obtain certificates of insurance evidencing coverage? Yes No Maintain written contracts with hold harmless and indemnity language? Yes No (attach a copy of same) The applicant uses the same subcontractors: <31% of the time; 31% - 50% of the time; 51% - 100% of the time As a general contractor, how many new homes were built in the last year? How many will be built this year?
General Liability Contractors Supplemental Account Name Effective Date in Business Under this Name: Years of Experience in this Field: Type of License: #: Year Issued: Has the applicant ever operated any other name? If so, state the reason for the name change. Indicate type of work performed by the insured and subcontractors: (total should equal 100%) Subs Insured Subs Subs Asbestos Abatement % % Levee Work % % Sewers % % Blasting % % % % Sheet Metal % % Bridge Building % % Masonry % % Sheet (Ornamental) % % Carpentry % % Mechanical % % Soil Stabilization % % Concrete % % Mold % % Street/Road Construction % % Drilling % % Painting % % Structural Demolition % % Electrical % % Pile Driving % % Supervisory Only % % Excavation % % Plastering % % Tunneling % % Fire Restoration % % Plumbing % % Underpinning Work % % Gas % % Pollution Abatement % % Wrecking/Demolition % % Insulation % % Roofing % % Restoration Work % % Other Services (specify) % % Indicate the percentage of work performed by the applicant: % PERCENTAGE OF OPERATIONS COMMERCIAL RESIDENTIAL Total Annual Revenue $ Total Annual Revenue $ General Contractor % New Construction % New Construction % Subcontractor % Remodeling % Remodeling % Construction Manager % Other % % number of employees (including owner and all leased employees): Total - Full Time Part Time Estimate for Next 12 Months 2016 2015 2014 2013 Annual Receipts Employee Payroll Exec. Supervisor Payroll Cost of Subcontracted Work List all states in which the applicant has done business in the past and will do business in the coming year? What percentage of work is performed outside of the home state? Does the applicant always require subcontractors to: insurance for General Liability and Worker’s Compensation? Yes No Carry insurance for Business Automobile? Yes No If yes, list limits: Require equal limits in General Liability coverage? Yes No Name the applicant as an additional insured on all policies? Yes No Obtain certificates of insurance evidencing coverage? Yes No Maintain written contracts with hold harmless and indemnity language? Yes No (attach a copy of same) The applicant uses the same subcontractors: <31% of the time; 31% - 50% of the time; 51% - 100% of the time As a general contractor, how many new homes were built in the last year? How many will be built this year?
2017LouisianaGLGeneralContractorsSupplemental.docx