Contractor Ez Quote Form
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7Contractor EZ Quote Form
New Mexico Mutual 3900 Singer Blvd. NE Albuquerque NM 87109
* Please complete the General Information, Employee Information and Safety Information sections, along with the Risk Specific sections*
Completed By:
In addition to the supplemental information, please
attach the following if applicable:
Title:
3 to 5 Year Currently Valued Loss Runs
Associated Premium Figures
Date:
Experience Rating Worksheet
General Information
Company Name:
FEIN:
Contractor's License #:
Number of years experience in this industry:
Number of years managing in this industry:
Type of work performed and percentage for each:
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Industrial: ________%
Residential: ________%
Commercial: ________%
Type of work performed and percentage for each:
□
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Remodel: ________%
New Construction: ________%
Number of Stories Worked and Percentage of Each:
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1-2 Story Structures: ________%
3 or More Story Structures: ________%
Maximum Height of Operations:
Maximum Depth of Operations:
________ft.
________ft.
Business Operations:
(Please Check All That Apply)
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Plastering/ Stucco/Masonry (Pg. 4)
Plumbing/HVAC (Pg. 6)
Insulation (Pg. 7)
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Concrete (Pg. 7)
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Flooring (Pg. 4)
Electric (Pg. 6)
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Street/Road/Bridge Work
(Pg. 7)
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Roofing (pg. 4)
Utility/Excavation(Pg. 6)
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Demolition < 10% of Operation
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Landscaping (Pg, 5)
Painting (Pg. 7)
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Other:________________
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Carpentry (Pg. 5)
Drywall (Pg. 7)
*Note - If box is checked, please complete the EZ Quote sections that apply to the applicant.*
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What is the typical size of the crew? ________
Is there an onsite foreman?
Yes
No
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Parent category: Financial