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1.
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Your Sales Agent's Name:
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2.
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Name of Company:
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DBA:
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3.
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Type of business organization:-
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4.
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State in which articles of organization or incorporation are filed:
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5.
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How long has Company been manufacturing or selling/installing manufactured and/or modular homes under its current name?
*
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6.
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How many homes do you estimate you will enroll in the next 12 months?
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7.
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List all Principals owning 10% or more of the Company
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(please email
builderapps@strucsure.com if there are more)
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8.
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Has Company or any of its Principals ever filed bankruptcy or been adjudicated
bankrupt within the past 5 years?
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If yes, please provide details:
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9.
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Has Company ever experienced any workmanship, and/or construction defect litigation claims?
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If yes, please provide details:
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10.
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Is the Company required to obtain a general contractor’s license from the locale in which it operates?
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If “Yes” please list license number(s) and Jurisdiction(s)
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11.
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Provide Company’s General Liability Insurance Carrier below. Please fax or eMail your Certificate of Insurance to StrucSure.
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Policy #:
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Fax:
Expiration Date:
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Please be prepared to provide your loss run from your General Liability insurance
provider when you send in your Certificate of GL coverage.
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The undersigned further consents to StrucSure Home Warranty’s use of a non-business consumer credit report on the
undersigned as an Owner or Principal of the Applicant in order to further evaluate the creditworthiness of the undersigned
in connection with the investigation of the financial and technical ability of the Applicant to meet its warranty obligations
to Homeowners, StrucSure Home Warranty, LLC and the warranty Insurer. The undersigned hereby authorizes StrucSure
Home Warranty, LLC to utilize a consumer credit report on the undersigned and hereby knowingly consents to the use of
such credit report consistent with the Federal Fair Credit Reporting Act as contained in 15 USC 1681 et seq. Registration fee is non-refundable.
I hereby certify that all of the above information is true and correct to the best of my knowledge. I have read and agree to
the terms of the Golden Builders Association Membership Agreement.
THIS APPLICATION IS BEING EXECUTED BY AN ELECTRONIC SIGNATURE. THE UNDERSIGNED AGREES TO BE BOUND BY
THE ELECTRONIC SIGNATURE AND FURTHER AGREES THAT ANY SUCH ELECTRONIC SIGNATURE SHALL BE EQUALLY
EFFECTIVE AS THOUGH IT WERE AN ORIGINAL.
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Name of Person agreeing to these terms and conditions:
*
MUST BE A PRINCIPAL OF THE COMPANY
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Please enter anti-spam code below
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