AAA111 Vendor Test Fields marked with an * are required 1Contact & Billing Information2Ownership Structure3Territory Covered by the Vendor4Trades5Qualification6Document Upload7Acknowledgement Contractor/Company Name* Doing Business as Company Owner (Primary) Name* Contact Name Office PhoneCell PhoneFax PhoneEmail* Website Federal Tax ID Number* Physical Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Mailing Address (if different from physical) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Billing Company Name* Billing Contact Name* Billing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Are you currently using Xact Analysis and or Symbility? If so, Please provide your:Xact Analysis address SYMBILITY ID Pick One*CorporationSole ProprietorPartnershipLimited Liability CompanyPublicly TradedDivision, Subsidiary, or Affiliate of a Public Traded CompanyOtherFor Publicly Traded CompaniesTraded Company Stock Symbol Listing Exchange Principal #1Full Name* Social Security Number* Date of Birth* % of Ownership* Driver's License Number* Active* Yes No Principal #2Full Name Social Security Number Date of Birth % of Ownership Driver's License Number Active Yes No Principal #3Full Name Social Security Number Date of Birth % of Ownership Driver's License Number Active Yes No Principal #4Full Name Social Security Number Date of Birth % of Ownership Driver's License Number Active Yes No *Personal addresses for all principals may be needed for credit reporting purposes.About Your CompanyFacility #1 Name Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Warehouse #1 sq. ft. Facility #1OwnedLeasedFacility #2 Name Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Warehouse #2 sq ft Facility #2OwnedLeasedFacility #3 Name Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Warehouse #3 sq ft Facility #3OwnedLeasedCompany EquipmentFlatbed Trucks Owned Flatbed Trucks Leased VansVans Owned Vans Leased Pick Up TrucksPick Up Trucks Owned Pick Up Trucks Leased OtherOther Description/Name Other Owned Other Leased OzoneOzone Rooms Owned Ozone Rooms Leased GeneratorsGenerators Owned Generators Leased Tell us more about your company (Last 3 Years)Enter Current Year* Number of Residential Jobs YTD* % Residential Jobs YTD* Largest Single Residential Job YTD* Average Residential Job Amount YTD* Enter Current Year* Number of Commercial Jobs YTD* % Commercial Jobs YTD* Largest Single Commercial Job YTD* Average Commercial Job Amount YTD* Enter Year of Largest Job* Amount of Largest Single Residential Job* Year of Largest Commercial Job* Amount of Largest Single Commercial Job* Average Job Amount All Combined* Do your Employees Wear Uniforms?* Yes No Are your company vehicles marked?* Yes No Do your employees carry proper company identification?* Yes No Does your company meet the states minimum statutory requirements for Workers Compensation Insurance? Yes No Legal IssuesHas your business been involved in litigation in the last four (4) years?* Yes No If so, please explain, including dates, opposing parties, state, and county.*Has your business ever filed for bankruptcy? Yes No If so, what is the current status?*Has your business ever had a license suspended or revoked? Yes No If so, list the license(s):*Has any principal been in any litigation in the past four (4) years? Yes No If so, please explain, including dates, principal, opposing parties, state, and county:*Has any principal ever filed for bankruptcy? Yes No If so, please explain, including principal and current status:*Has any principal ever had a professional license suspended or revoked? Yes No If so, please explain, including, principal and license(s):*Has any principal ever used an alias?* Yes No If so, please explain, including principal and alias:* Cities CoveredCounties CoveredZip Codes CoveredYou may choose to upload the information Drop files here or Select files Accepted file types: xls, csv, xlsx, pdf, jpg, gif, png, doc, docx, Max. file size: 10 MB. CONTENTSPack-out? Yes No Pack-in? Yes No Carpet Cleaning? Yes No Content Cleaning? Yes No General Cleaning? Yes No % Contents Subbed Out WATER MITIGATIONCommercial Mitigation? Yes No Residential Mitigation? Yes No % Water Mitigation Subbed Out REMODELINGRemodeling? Yes No ROOFINGRoofing License? Yes No Roofing Sub Out % Roof Type Flat Tile Metal (check all that apply)GENERAL CONTRACTINGGeneral Commercial Contractor? Yes No General Residential Contractor? Yes No % General Contracting Subbed Out EMERGENCY FIRE AND SMOKE (Includes Board up)Emergency Fire and Smoke? Yes No Security? Yes No Ozone? Yes No Temporary Utility Service? Yes No % Emergency Fire and Smoke Subbed Out LARGE LOSSCommercial Large Loss? Yes No Residential Large Loss? Yes No SPECIALTY SERVICESArt Restoration? Yes No Cabinets Catastrophe? Yes No Furniture Refinishing? Yes No Asbestos Abatement? Yes No Earthquake Retrofit? Yes No Mold Remediation Salvage? Yes No If employees, subcontractors or tradespeople are hired to work on any Direct Claims Management Group assigned job, it is the responsibility of the Direct Claims Management Group contractor to determine if they are fully Licensed/certified and qualified to perform the work that is being assigned to them. If any wrongdoing, mishandling, and/or negligence is caused by the employee, subcontractor, or tradespeople; it is the Direct Claims Management Group contractor who is solely responsible and must correct the action/problem as soon as it is recognized. I have read and understand the above Qualification Statement and agree to its terms and conditions: * Agree Agree Disagree FIRE | SMOKE | MOLD - CLEANINGIs all of your General Cleaning work handled in-house? Yes No Do you have Clean-room? Yes No Do you have on-site Storage? Yes No Do you have inventory tracking software? Yes No If any Clean Up work is sub-contracted out, please explain:CONTENTS CLEANING PROGRAM (Pack-out/Move Back)Are you or any employee capable of lifting 50 pounds or more? Yes No Do you have Flatbed trucks to transport all contents? Yes No Do you have digital cameras? Yes No BOARD UPAre you capable of handling emergency board up, and roof tarping? Yes No Is all of your Board Up work handled in-house? Yes No If any Board Up work is sub-contracted out, please explain:Is an employee from your company present to oversee all Board Up work? Yes No If not, please explain:Do you currently carry a Bailment insurance policy?* Yes No If not, would you be willing to do so, please explain:Please use the space below to indicate an explanation for any question that was answered WhyOnce selected for a program, you will need to meet all program requirements (listing of program requirements enclosed in this package). If you do not have the necessary insurance coverage or currently utilize Xactimate, we are not asking you to take steps to meet our requirements until you have been selected by a client. We want you to be aware of the requirements for the future. Prior to activation on a program you will also be required to sign a service level agreement. Name First Last Completing Company Name W-9 Form* Drop files here or Select files Accepted file types: xls, csv, xlsx, pdf, jpg, gif, png, doc, docx, Max. file size: 999 MB, Max. files: 3. Please upload your completed W-9 formCertificates and Licenses* Drop files here or Select files Accepted file types: xls, csv, xlsx, pdf, jpg, gif, png, doc, docx, Max. file size: 999 MB, Max. files: 8. Please upload copies of any licenses required by your state and all states you do work in for the following areas: Contracting License Operating License Contracting Registration Environmental Protection Agency (EPA) Lead Renovation, Repair, and Painting (RRP) All licenses must be in the company's Doing Business As (DBA) NameFacility Photos* Drop files here or Select files Accepted file types: xls, csv, xlsx, pdf, jpg, gif, png, doc, docx, Max. file size: 999 MB, Max. files: 20. Front of building space including signage Inside office space Company vehicles including signage Storage areas Equipment: please take one to two photos of your equipment available to you on siteInsurance Requirements* Drop files here or Select files Accepted file types: xls, csv, xlsx, pdf, jpg, gif, png, doc, docx, Max. file size: 999 MB, Max. files: 20. General Auto Workers Compensation Pollution s/ Excess Bailment Coverage Background Checks* Drop files here or Select files Accepted file types: xls, csv, xlsx, pdf, jpg, gif, png, doc, docx, Max. file size: 10 MB, Max. files: 5. For all employees working on or with DCMG claimsFinancials* Drop files here or Select files Accepted file types: xls, csv, xlsx, pdf, jpg, gif, png, doc, docx, Max. file size: 10 MB, Max. files: 5. Profit & Loss for previous 2 full calendar years and YTD Please read, sign and date that you understand the following statements. All owners must sign individually. Please mail original signed document. ACKNOWLEDGEMENT STATEMENT We, the undersigned, hereby grant Direct Claims Management Group, permission to make any and all desired inquiries, order credit reports and order narrative reports on our company and each of the undersigned. We, the undersigned, hereby grant Direct Claims Management Group, permission and approval to assess the information submitted and provides an overall recommendation based on the information. The application is confidential and not binding in any way upon with Direct Claims Management Group or the undersigned applicant. We, the undersigned, acknowledge and attest that the information provided in this application is true, to the best of our knowledge. We, the undersigned, acknowledge that any current or past criminal charges against the principals have been disclosed to Direct Claims Management Group. We, the undersigned, hereby agree that the application itself is copyrighted and confidential to Direct Claims Management Group and will be protected as such. In addition, Direct Claims Management Group agrees that the applicantâs information is confidential to the application and will be protected by Direct Claims Management Group with the understanding, however, that Direct Claims Management Group reserves the right to freely disseminate the applicantâs information to Clients of Direct Claims Management Group without notification to applicant. LEGAL ISSUES I/We certify under penalty of perjury, that the legal issues provided in this application are complete, true, and correct.QUALIFICATION STATEMENT If employees, subcontractors or trades people are hired to work on any Direct Claims Management Group assigned job, it is the responsibility of the Program Contractor to determine if they are fully licensed/certified and qualified to perform the work that is being assigned to them. If any wrongdoing, mishandling, and/or negligence is caused by the employee, subcontractor, or trades people, it is the Program Contractor who is solely responsible and must correct the action/problem as soon as it is recognized. APPLICATION FEE We acknowledge a thorough review of all application documentation submitted will occur, and that the application fee is non-refundable. Application Fee - $599 All Owners Must Sign IndividuallyI, the Applicant, for this application to participate in the Direct Claims Management Group, warrant the truthfulness of the information provided in this application. Please type First and Last Name. TERMS OF ACCEPTANCE and SIGNATUREElectronic Signature Owner 1* First Last I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance (1)* Accept Electronic Signature Owner 2 First Last I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance (2) Accept Electronic Signature Owner 3 First Last I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance (3) Accept Electronic Signature Owner 4 First Last I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance (4) Accept Required* I have read and understand the Terms and Conditions You may be charged multiple times if you click the Submit button more than once. Application Fee* Price: EmailThis field is for validation purposes and should be left unchanged. Δ
