Agent Form

Highlands Agency Untitled Document

Your Name:
Your Email Address:
Client Name:
Client Web Site - If none type NONE:
How Many Years In Business?
How many employees? Over 10 does not qualify.
Annual gross receipts: Over 2.5 million does not qualify.
What percentage of work is subcontracted? Over 25 percent does not qualify.
Does applicant require USL&H or other federal coverage (Jones Act, etc.)? If YES - does not qualify.
Does applicant perform any work for utilities, municipalities or other public entities? If YES - does not qualify.
Does applicant build and use vertical forms? If YES - does not qualify.
Does applicant own or use scaffolding or scissor lifts?
Provide complete description of applicant's operations:
Percentage of Residential Work:
Percentage of Commercial Work:
Does applicant provide PPE (gloves, boots and eye wear) to employees and mandate its use?
Are hand trucks and other equipment provided for moving bulky or heavy items?
Have employees been trained in proper lifting techniques and in the correct use of material handling devices?
Provide specific description of operations subcontracted (roofing, carpentry, etc.). (Aplicant must obtain Certificates of WC coverage from all subcontractors).
Provide radius of operation:
Does applicant screen drivers (check MVRs pre-employment and annually thereafter)?

Please enter the combinations of letters and numbers. The letters are not case sensitive.

Concrete Contractor