NYSEC Application NEW YORK STATE ASSOCIATION OF ELECTRICAL CONTRACTORS INSURANCE PROGRAM APPLICATION Step 1 of 5 20% Name * RequiredName of Business:PhoneEmail Address: * RequiredAddress:Web Site:Years in Business:mm/dd/yyyy Property Information: (Provide for Each Location Insured)Policy Effective Datemm/dd/yyyyLocation 1Location Address:Building Limit:Construction Type:Contents Limit:Square Footage:Year Built:Year of Remodeling:Other Occupancies:Location 2Location Address:Building Limit:Contents Limit:Construction Type:Square Footage:Year Built:Year of Remodeling:Other Occupancies:Location 3Location Address:Building Limit:Contents Limit:Construction Type:Square Footage:Year Built:Year of Remodeling:Other Occupancies:*Inland MarinePolicy Effective Datemm/dd/yyyyPlease list a schedule of equipment you'd like to insure: How many jobs a year do you do?Commercial:Residential:What is the job size:Smallest: $Largest: $*General Liability:Policy Effective Datemm/dd/yyyy1. What type of electrical work do you do?2. Total Gross Annual Sales: $3. What is your total Field Payroll (not clerical or sales people): Break it down as follows:Wiring of Buildings:Street or Traffic Lights:Machinery:Interior of offices for computers and phones:Fire or Burglar Alarms:Other:Do you Use Subs?If so, what do they do?Total w/ annual cost of subs:Who supervises the subs on the jobsite, and how often does that occur?Do you require certificates of insurance from all subs? CGL Limits required:Occurrence:$Aggregate:$Do you require subs to sign written construction contracts containing indemnity / hold harmless clauses in your favor?*AutomobilePolicy Effective Datemm/dd/yyyyFrom your current policy, list the schedules of automobiles to insure. It should include VIN #’s, comprehensive and collision deductibles, etc.*Umbrella:Policy Effective Datemm/dd/yyyyWhat limit would you like us to quote?4 years of loss history will be required prior to binding coverage.NameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.