NEW BUILDER RUSH REGISTRATION : $595

Thank you for your interest in becoming a member of StrucSure Home Warranty. The first step to getting insurance-backed warranty coverage on the homes you build and sell is filling out our Builder Membership Application below. Once this application is received and approved and all applicable membership fees are paid, we will send you login credentials for our online builder portal (within one business day for rush registrations). This portal is where you will enroll your properties for warranty coverage. If you have questions regarding this application or our warranty process, please contact us.

SHW Representative:

Name of Company:

DBA:

Billing Address:

City:

State:

Zip:

Mailing Address:

City:

State: Zip:

Phone Number:

Fax Number:

Cellular Number:

Email Address:

Web Site:

Contact Person:

Federal Employers ID #:

Parent Company:

Type of Business/Org.:

Sole Proprietor

Partnership

Corporation

Other

State in which articles of organization or incorporation are filed:

How many years as Company been building under its current name?:

List all principals owning 10% or more of the Company

Name:

Title:

SSN:

Name:

Title: SSN:

Name:

Title: SSN:

(Please email builderapps@strucsure.com if there are more than three)

Has Company or any of it's Principals ever filed bankruptcy or been adjuncted bankruptcy within the past 5 years?

Yes

If Yes, please provide details:

Has Company ever experienced any workmanship/system, structural and/or construction defect litigation claims in the past 5 years?

Yes

If Yes, please provide details:

Is Company required to obtain a general contractor's license from the jurisdiction in which it operates?

Yes

If Yes, please list license number(s) and jurisdiction(s):

10.

List all building department jurisdictions in which you build or intend to build.

Phone #

(Please email builderapps@strucsure.com if there are more than three)

11.

List Companys current General Liability Insurance carrier:

GL Carrier Name:

Policy #

GL Carrier Address:

GL City:

State: Zip:

GL Broker/Agent Name:

GL Phone Number:

GL Fax Number:

GL Policy Expiration:

12.

How many homes will you enroll with StrucSure over the next 12 months?

Average sales price: $

13.

In an effort to understand the impact of our marketing efforts (and dollars), will you please quickly tell us how you learned about StrucSure Home Warranty?

General Marketing / Communications:

Referral Who Referred you?

Other Other Reason:

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.

Name of Person agreeing to these Terms/Conditions: MUST BE A PRINCIPAL OF THE COMPANY