Artisan Contractor - Trysail Insurance Agency

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Company Name

Type of business

Business Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Business Web Address

Contact Name

Contact Phone

Contact Email

When do you need Insurance Coverage by (Renewal Date)

Artisan Contractor Form

Last 3 Year Gross Revenue:

Year:

Revenue:

Year:

Revenue:

Year:

Revenue:

Last 3 Years Payroll:

Year:

Revenue:

Year:

Revenue:

Year:

Revenue:

List any claims that you may have had in the last 5 years

Description of Marine Operations and Work

Description of Non-Marine Operations

Parentage of your Operations that are

Marine %

Non-Marine %

Do you use Subcontractors or Leased Workers

Yes
No

What Percentage of Work is Subcontracted? %

Are Certificates of Insurance Obtained from Subcontractors

Yes
No

Do you have a formal safety program in place

Yes
No

Any Exposure to Flammables, Chemicals or Explosives

Yes
No

Any Blasting Operations or Storage of Explosives

Yes
No

Any Bridge Work

Yes
No

Does Applicant Draw Plans, Designs, or Specifications

Yes
No

Does Applicant Lease Equipment to Others With or Without Operators

Yes
No

Number of Owned or Operated Watercraft

Additional Information / Questions