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If you know your Member ID # or e-mail and password, you may enter them here to have the form pre-filled for you.
Member ID # or e-mail:
Password:
Existing Foundation Repair Renewal Registration
Please complete the Foundation Repair Membership Application below to apply for membership in our warranty program. If you have questions, please
contact us
.
Membership Registration
$
399
1.
Name of Company:
*
DBA:
Address:
*
City:
*
State:
*
Zip:
*
Mailing Address:
City:
State:
Zip:
Phone:
*
Fax:
Email Address:
*
Cell:
Contact Person:
*
Federal Employers ID #
*
Parent Company:
2.
Type of business organization:-
Sole Proprietor
Partnership
Corporation
Other
3.
State in which articles of organization or incorporation are filed:
4.
How long has Company been performing foundation repair projects under its current name?
*
5.
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)
6.
Has Company or any of its Principals ever filed bankruptcy or been adjudicated bankrupt within the past 5 years?
Yes
No
If yes, please provide details:
7.
Has Company ever experienced any workmanship, and/or construction defect litigation claims?
Yes
No
If yes, please provide details:
8.
Is the Company required to obtain a general contractor’s license from the locale in which it operates?
Yes
No
If “Yes” please list license number(s) and Jurisdiction(s)
9.
Provide Company’s General Liability Insurance Carrier below. Please fax or eMail your Certificate of Insurance to StrucSure.
General Liability Carrier Name:
*
Policy #:
*
GL Carrier Address:
*
GL Broker/Agent Name:
*
GL Phone:
*
Fax:
Expiration Date:
*
Please be prepared to provide your loss run from your General Liability insurance provider when you send in your Certificate of GL coverage.
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 and conditions:
*
MUST BE A PRINCIPAL OF THE COMPANY
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