Contractor Renewal Form

NAME *First

BUSINESS NAME *

EMAIL *

HOW MANY EMPLOYEES DO YOU HAVE? *

TOTAL ESTIMATED GROSS
ANNUAL REVENUE *

TOTAL ESTIMATED GROSS ANNUAL W2 PAYROLL *

TOTAL ESTIMATED GROSS ANNUAL 1099 CONTRACTOR COST (INSURED) *

IF INSURED SUBCONTRACTORS ARE USED, DO THEY PROVIDE YOU WITH A CERTIFICATE OF INSURANCE LISTING YOU AS AN ADDITIONAL INSURED *—Please choose an option—YesNo

TOTAL ESTIMATED GROSS ANNUAL 1099 CONTRACTOR COST (UNINSURED) *

PLEASE PROVIDE DESCRIPTION AND VALUE ON YOUR 3 CURRENT OR RECENT PROJECTS *