Welcome to Bkamran Insurance Services, Inc.

CONTRACTORS

PERSONAL INFORMATION

* Mandatory fields

Quote Date :

First Name :	*

Last Name :	*

Mailing Address :	*

City :	State: Zip Code: *

Home No. :	*

Cell No. :	*

Business No. :

E-Mail. :	*

Current Policy Expiration Date :

Social Security No. :

Location of Garage : (if diff. from Above)

City :	State : Zip Code :

Choose from the Following:

COMPLETE SUPPLEMENTAL QUESTIONNAIRE

Is this questionnaire for :	New Business? Renewal Business?

If “renewal” give current policy number :

INSURED

When did the applicant's business start?

How long has the applicant been in this line of work? :

Is or has the applicant ever been involved in any other business venture as an owner or officer?	if Yes

explain:

. Has this business or any other business in which the insured is or was involved as an owner or officer ever declared bankruptcy?	if Yes

explain:

What classes of contractors licenses does the applicant hold?

License number(s) :

EMPLOYEES

Provide the following information concerning employees for the past three years and give an estimate for the next 12 months:

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Number of Full-time Employees	Number of Part-time Employees

PAYROLL AND RECEIPTS

Provide the following information for the past three years (use audited information if possible) and give an estimate for the next 12