REMODELER RENEWAL : $295

Thank you for your interest in the StrucSure Remodelers Program^TM. Please fill out the form below to apply for your membership in this program at a cost of $295. Once we have received and reviewed your application and payment, we will contact you with next steps.

If you know your Builder Number and password, you may enter them here to have the form pre-filled for you.

Member Number:
Password:

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 has the Company been remodeling 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 remodeling contract 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:

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