48 Hour Questionnaire
Please note, you are in a secure area
Type of Business Individual Co-Partnership Corporation
Company Name
Address
City/State/Zip
Phone
Fax
Email
Type of Work Geographic Area
Business Net Worth $ How long in business
Have you ever been Bonded? NO YES
Explain:

INDEMNITOR INFORMATION. Provide this information on all owners.
Ever declared bankrupt? NO
YES
Explain:
Ever declared bankrupt? NO
YES
Explain:
Any pending Suits or Liens NO
YES
Explain:
Any pending Suits or Liens NO
YES
Explain:

Name Name
Title Title
Address     #        Street Name      St./Ave.
Address     #        Street Name      St./Ave.
City/State/Zip City/State/Zip
Social Security # Social Security #
Spouse Name Spouse Name
Social Security # Social Security #
Personal Net Worth Personal Net Worth
% Of Ownership % Of Ownership

 
LIST THE THREE LARGEST CONTRACTS COMPLETED IN THE LAST FIVE YEARS
Owner Type of Work Contact Name
& Phone #
Amount Year Disputes
(Y/N)

LIST 5 MAJOR SUPPLIERS SUBCONTRACTORS WITH WHOM YOU HAVE DONE BUSINESS
Name Amount Owed % Over
60 Days
Contact Name & Phone #

LIST THE 3 LARGEST JOBS YOU HAVE UNDERWAY
Owner/General Contact Name
& Phone #
Type of Work Contract $$ % Comp Date Comp
Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or application containing any false, incomplete, or misleading information is guilty of a felony per state statute.
By submitting information through this site, I authorize you and/or the surety to contact the individuals and companies given as references or other sources to gather information on the credit, character and capacity of the individuals and the company.
Name: Title: Date:
Press the Submit button below to submit your 48 Hour Questionnaire, or you can fax it or email it to: fax (561) 997-7087 or email to: bonds@beacongroupinc.com. or call 1-800 545-9007 ext. 133
Richard S. Wurst, ARM, AAI - License D048332 (Office use only)



 



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