Installer Application

Business Name*
Business Address*
Street Address Address Line 2 City State ZIP Code
Owner/Officer Name*
First Last
Title*
Email*
Phone*
Type of Entity*
Date Business Established*
Date Format: MM slash DD slash YYYY
Tax ID*
Number of Employees*
(if applicable)
Last Year
Previous Year
Previous Year
Insurance Requirements
- General Liability with a required limit of no less than $1,000,000 each occurrence for bodily injury and property damage $2,000,000
- Worker’s Compensation with the required limit of no less than $500,000 each accident, $500,000 Disease policy limit, $500,000 Disease each employee
- Excess Liability Umbrella Policy with the required limit of no less than $1,000,000 each occurrence, $2,000,000 aggregate
- Automobile Liability Insurance combined single limit of $1,000,000 for bodily injury and property damage per each
- Additional Insured-DHIAA
Attach COI
Accepted file types: doc, pdf, txt.