COMPANY INFORMATION

Company Name:

Select... Corporation LLC Partnership Sole Proprietor Other (List in Name)

Main Contact Person:

Street Address:

City:

  State: -- PANJAKALAR AZCACOCTDC DEFLGAHIIA IDILINKSKY LAMAMDMEMI MNMOMSMTNC NDNENVNHNJ NMNYOHOKOR PARISCSDTN TXUTVAVTWA WIWVPR   Zip:

Phone Numbers:

Work:   Cell:   Other:

Email Address:

Federial ID Number:

Social Security Number:

Insurance Carrier's Name:

Commercial General Liability Insurance:
$1,000,000 Each Occurrence Limit (Bodily Injury & Property Damage)
$2,000,000 General Aggregate
$2,000,000 Products & Completed Operations Aggregate
$1,000,000 Personal & Advertising Injury Limit

Business or Commercial Automobile Liability Insurance:
$1,000,000 Combined Single Limit per Accident

Workers' Compensation & Employers' Liability Insurance:
$100,000 Each Accident
$100,000 Each Employee for Injury by Disease
$500,000 Aggregate for Injury by Disease

Excess or Umbrella Liability:
$1,000,000 Occurrence/Aggregate

Additional Insurance Information:

COMPANY DETAILS

Number of Employees:

Can you Provide At Least One Employee Per Job That Can Communicate in English:

Are your Employees E-Verified:

Can your Employees Pass a Drug Test:

Can your Employees Pass Background Checks:

Can your Company Do Certified Payroll:

Are You Able to Work Piece Rate:

What is Your Hourly Rate:

How Many Employees Have OSHA 10/30:

How Many Employees Have Lift Certification:

SPECIAL QUALIFICATIONS OR SKILLS

Use this space to describe any special qualifications or skills you have acquired through special training, prior employment or general experience.

EXPERIENCE

BUSINESS REFERENCES

List names and address of three former construction related employers:

Reference #1:

Address:

Phone Number:

Reference #2:

Address:

Phone Number:

Reference #3:

Address:

Phone Number:

Additional Comments:

APPLICANT'S STATEMENT

                By clicking Agree below, I attest that I am an independent contractor and that all
                information is true and correct. I authorize investigation of all statements made herein by me.

                I have read and understand the above statements
                and I agree with the terms stated:  AGREE