New Subcontractor Info Form

Company Name *

First Name

Last Name

Name of Managing Member of Company Above *

First Name

Last Name

Phone *

(###)

###

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Are you a managing member, or owner of the company listed above? *

Yes

No

Does your company carry a commercial general liability policy with at least 1,000,000/2,000,000 policy Limits? *

$1,000,000 for any one occurance, $2,000,000 Aggregate

Yes

No

I understand that Herbst Homes LP must me listed as additional insured on my companies general Liability policy *

Yes

No

Does your company carry a commercial auto policy? *

Yes

No

What type of workers compensation coverage does your company have *

Workers Comp policy covering all officers, employees, and subcontracted labor

All Employees, and Subcontractors used by my company have active exemptions

My company uses an employee leasing company for workers compensation coverage

I do not have workers compensation coverage

If your company utilizes an employee leasing company, which option best describes your company * *

My company does not use an employee leasing company for workers compensation

My company uses a leasing company for workers compensation coverage, and only the individuals listed on an active roster employed by my company are authorized to perform work. We do not subcontract any labor.

My company uses a leasing company for workers compensation coverage. My company utilizes subcontractors, and my company maintains all workers compensation insurance documentation in accordance with the Florida Division of Workers Compensation.

I understand that I cannot be present, or perform work on a Herbst Homes Jobsite, until I have been fully processed. This will occur once I receive written approval from Herbst Homes stating all documentation has been received, and I am officially processed. *

Yes, I understand