nfr independent contractor application packet...nfr is under no obligation whatsoever to assign job...

9
NFR Independent Contractor Application Packet The NFR Independent Contractor Application Packet contains five forms: page 2 - 5 - Background Information Form For Independent Contractor page 6 - Independent Contractors Agreement Page 7 - Independent Contractors Service Level Agreement Page 8 - Independent Contractors Privacy Agreement Page 9 - W9 To submit your NFR Independent Contractor Application you need to complete the following two steps: 1. Please fill out, on your computer, the "Background Information Form For Independent Contractor" on pages 2 through 5 in this packet. When you are done, please click on the "Submit by Email" button on the bottom of page 5 and follow the instructions. 2. Please print out, fill out and sign pages 6 through 9 of this packet, which contain the "Independent Contractors Agreement", the "Independent Contractors Service Level Agreement", the "Independent Contractors Privacy Agreement" and the "W9". When you are done, please mail, fax or email the completed forms to us. When we have received all this information we can process your application. We look forward to working with you! National Field Representatives, Inc. Contractor Services Department PO Box 1440 Claremont, NH 03743 Phone 800-639-2151 ext. 243 Fax 603-543-0412 Email [email protected]

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  • NFR Independent Contractor Application Packet The NFR Independent Contractor Application Packet contains five forms: page 2 - 5 - Background Information Form For Independent Contractor page 6 - Independent Contractors Agreement Page 7 - Independent Contractors Service Level Agreement Page 8 - Independent Contractors Privacy Agreement Page 9 - W9 To submit your NFR Independent Contractor Application you need to complete the following two steps: 1. Please fill out, on your computer, the "Background Information Form For Independent Contractor" on pages 2

    through 5 in this packet. When you are done, please click on the "Submit by Email" button on the bottom of page 5 and follow the instructions.

    2. Please print out, fill out and sign pages 6 through 9 of this packet, which contain the "Independent Contractors Agreement", the "Independent Contractors Service Level Agreement", the "Independent Contractors Privacy Agreement" and the "W9". When you are done, please mail, fax or email the completed forms to us.

    When we have received all this information we can process your application. We look forward to working with you!

    National Field Representatives, Inc. Contractor Services Department PO Box 1440 Claremont, NH 03743 Phone 800-639-2151 ext. 243 Fax 603-543-0412 Email [email protected]

  • Background Information Form For Independent Contractor

    First Name*

    Last Name*

    Company Type

    Mailing Address*

    City* State* Zip*

    Physical Address

    State Zip

    Check if physical address is the same as mailing address

    City

    Office Phone* Home Phone

    Fax Fax is available 24 Hours a Day

    Inspection Cell Preservation Cell

    Emergency Contact:

    Name Phone

    Email Address*

    Personal Information:

    Phone Numbers & Email:

    Page 2 of 9

    Instructions: 1. All fields marked with an asterisk (*) are required. 2. We need three references (page 5) in order to process your application. 3. The correct entry of zip codes (page 5) is very important. We assign work to contractors based on this information.

    You may enter a single zip code, a range of zip codes, or a list of zip codes and you may combine all of these styles. See the examples above the zip code entry boxes for details.

    Tip 1: Review the form and collect all your data elements before you start. This may save you a lot of time. Tip 2: You may save your application at any time, so you can come back to it later. Tip 3: We highly recommend that you print and file a copy of your filled in form for future reference and save your

    completed form to your computer.

    Please enter phone numbers as 10 digits only; do not use dashes, spaces or parenthesis

  • Interview & Inspect

    24 Hour Rush 72 Hour Rush

    Walk Thru Insurance Loss

    5 Day Rush Sale Date

    ROV Commercial

    Property Preservations:

    Business Classification Certification #

    How do you control quality?*

    Are you a NAMFS Member?*

    Are you a ASHI or NACHI Member?*

    General Information:

    Please describe your background in business in general, and in field services:

    Preservation Discount

    Number of years in business

    Inspections:

    Property Inspection

    Do you perform inspections?*

    Do you perform property preservation?*

    If you perform inspections, please provide us with your pricing information:

    Do you have a working knowledge of all investors guidelines (HUD, FNMA, FMAC, VA)?*

    Page 3 of 9

    Have you completed the Lead Renovator Training Course?*

    Business Classification*

    HUD Pass Reac Certification M#

  • Do you carry E&O Coverage?*

    Do you carry Auto Insurance?*

    Page 4 of 9

    Insurance:

    General Liability Carrier*

    Will you agree to list National Field Representatives as an additional insured?*

    Please describe any court issued judgements you have had against you:*

    Please describe any insurance claims you have had in the last 3 years:*

    Please describe any felonies you, or any other principals, have ever been charged with:*

    Employees:

    How many employees do you have?* How many are covered by Workers Comp?*

    If you do not carry Workers Comp, please explain why not?

    How many sub-contractors do you use?*

  • What zip codes do you propose to cover for NFR? Please enter zip codes that you cover on a routine basis in by using the following formats: Single zip - 03743 Range of zips - 03743-03849 (to indicate that you will cover all zips in between and including 03743 and 03849) Range of zips - 037 (to indicate that you will cover all zip codes starting with 037) List of zips - 03001,03743,03601 List of zips - 03001,03601-03694,037 (to combine single zips and ranges) A minimum of one zip code in either the Inspection or Preservation catagory is required.

    Inspection Preservation Check if same as Inspection

    Click on this button to automatically email your application to NFR

    ZIP Codes:

    Please list three references utilizing companies for whom you are currently providing services, preferably field services. A minimum of three is required.

    Company Name Contact Name Phone

    Reference 1*

    Reference 2*

    Reference 3*

    References:

    Page 5 of 9

    Ext.

  • Page 6 of 9

    WHEREAS, (hereinafter "Contractor") has agreed to periodically and from time to time provide services to National Field Representatives, Inc. (hereinafter "NFR") in reference to inspection, field work, property preservation and other activities assigned by NFR; and, WHEREAS, the parties wish hereby to establish their legal relationship, duties and responsibilities; NOW THEREFORE, upon adequate consideration the receipt of which is hereby acknowledged, the parties hereby agree as follows: 1. The parties agree that Contractor shall serve as an independent contractor, and not as an employee or other agent or servant of NFR or its customers. 2. The parties agree that Contractor possesses such knowledge and expertise in field service, inspections, property preservation and related work that the parties rely upon Contractor utilizing said knowledge and expertise in the independent performance of duties assigned to Contractor by NFR. 3. Contractor agrees to undertake any and all work, if any, assigned to and accepted by Contractor in a prompt, professional, and expeditious manner, in full and complete compliance with all applicable law, FDCPA, governmental regulation, investor regulations, and in compliance with the time standards established by NFR. 4. Contractor shall solely be responsible for any and all taxes or other governmental payments due and payable from Contractor as a result of any and all monies earned by Contractor as an independent contractor of NFR. NFR shall not withhold any such funds from payments made to Contractor, and Contractor agrees to accept responsibility to properly file any and all tax reporting and tax payments required of him in reference to said income. 5. The parties acknowledge that NFR will provide tax reporting of said income to the Internal Revenue Service and any state or local taxing authority upon the basis of a 1099 form, on an annual basis or during such periods as is required by law. 6. The parties acknowledge that Contractor, as an independent contractor is not entitled to worker's compensation, disability, medical, retirement or any other benefits. 7. The execution and performance of this Agreement shall not constitute an employment contract, an agreement to continue use of the services of Contractor, or any other obligation in reference to continuation of the use of the services of Contractor by NFR. NFR is under no obligation whatsoever to assign job or work to Contractor. Either party may terminate this agreement at will, with or without cause, at any time, upon written notice to the other. The Agreement shall be construed under the laws of the State of New Hampshire. 8. In the event of a dispute between the parties, jurisdiction shall vest solely in the courts of Sullivan County, State of New Hampshire. Contractor assents to personal jurisdiction thereof. Date: Independent Contractor Signature: Please Print: Name: Company Name: Address: City, State Zip:

    Independent Contractor Agreement

  • Page 7 of 9

    To: National Field Representatives, Inc. PO Box 1440 Claremont, NH 03743 Please Print: Name: __________________________________________(We, us) Company Name: _______________________________________________________________ Address _______________________________________________________________ City, State Zip _______________________________________________________________ We provide certain services to you. In order for us to provide those services, you provide us with or you have provided us access to certain confidential information, including but not limited to mortgagor name, address, phone number, loan number, principal balance, monthly payments, default status, employment information, tenant/rent rolls and other information. We agree to not disclose to any other party the confidential information you provide to us, except as needed to employees and/or subcontractors to perform the services we have agreed to provide to you. We agree to only use the information to perform the service(s) we have agreed to provide to you. We agree to not use such confidential information for any purpose other than the specific business purpose for which it is furnished to National Field Representatives Inc. We agree to keep your customers’ information in our possession secure. We agree to protect against any anticipated threats or hazards to the security or integrity of such information. If the security of customer information is breached or in any way compromised while under our control, we agree to immediately notify you in writing and will take all steps practicable to minimize the harmful effects of the compromise. We agree that our obligations hereunder shall survive without limitation the expiration or termination of the Agreement be either party for any reason. Date: ___________________ Independent Contractor Signature: ___________________________________________

    Independent Contractor Privacy Agreement

  • Page 8 of 9

    INDEPENDENT CONTRACTOR SERVICE LEVEL AGREEMENT This Service Level Agreement covers field inspection and/or property preservation

    services provided by undersigned contractor to National Field Representatives, Inc. (NFR)

    1. SERVICES

    Contractor shall perform all requested and accepted orders in a professional workmanlike manner consistent with generally accepted industry standards. Contractor agrees to accurately complete information and services requested pursuant to each order and return results within the pre-determined time requirement. Contractor further agrees to be accessible to NFR for necessary follow-ups, status, updates, questions, etc. Communication and customer service will be regarded as an important requirement to fulfill. Contractor communication will be directed to the NFR coordinator shown on the order or any available team member.

    2. INSPECTIONS

    a.) Contractor agrees to fulfill instructions and time service requirements for all inspections. Regular property inspections (PI), interviews & inspects (I&I), 24 hr rushes (24HR), insurance loss (IL), 3 day rushes (3 DAY), 5 day rushes (5 DAY), sale date (SD), retail outlet verifications (ROV), special occupancy (SPOCC), construction status (CS), redemption expiration (RED EX) realtor care (RC), Commercial (COMM), REAC etc. have individual instructions as well as a due date noted on each request. Items returned incomplete or not within this time frame may be subject to being reduced to the next applicable pricing tier or no charge unless a specified exception is agreed by NFR.

    b.) Contractor agrees to promptly report to NFR if damages, violations, dangerous, or unusual conditions are found at any property.

    c.) Contractor agrees that all first time vacancies will be returned to NFR within 1 business day of the inspection date. d.) It is agreed that inspection cancellations can be undertaken at any time. If said inspection has already been completed upon

    receipt of cancellation notice the normal inspection charge will be applied. If inspection is not completed at time of cancellation the inspection order will be disregarded.

    e.) Contractor agrees to attempt contact with the owner, manager, and/or general contractor within 24 hours of receipt of an Insurance Loss Inspection order to schedule an appointment to meet at the property. Contractor agrees to promptly update the NFR coordinator of agreed inspection date and time. If contact cannot be made the contractor agrees to update NFR with this information.

    f.) Contractor agrees to promptly submit invoices after all required documents and required photos have been received and accepted by NFR. Contractor further agrees to submit invoice within 15 days of the inspection date. Invoice will include NFR's customer name (Mortgage Co.), loan number, inspection type, inspection date and agreed fee. NFR will not be obligated to pay any inspection invoices received more than 45 days after completion of the inspection.

    3. PRESERVATION

    a.) Property preservation will be completed within 3 days of receipt of the order unless otherwise indicated. A complete and legible Property Condition Report (PCR) will be submitted within 1 business day of completion of the order.

    b.) Contractor agrees to have a full working knowledge and understanding of investor guidelines. Contractor further agrees to follow all expressed instructions in their entirety as shown on the NFR order. Contractor agrees that conventional loans will be charged at FHA pricing.

    c.) Preservation trip charges will only be applied if contractor is unable to complete work on site for reasons beyond contractor control.

    d.) Contractor agrees to promptly submit invoices after all photos and required documents (i.e. dump receipts & city violations) have been received and accepted by NFR. NFR will not be obligated to pay any preservation invoices received more than 14 days after completion of the work.

    e.) Contractor agrees to resolve invoice issues and or supporting documentation problems within 3 business days of notification of the problem.

    4. PHOTOS

    a.) Contractor agrees to follow photo instructions outlined in the inspection or preservation orders. b.) Contractor agrees to submit all required photos with or prior to submission of invoice. c.) Digital photos will be sent 1 property per e-mail to: [email protected] (unless otherwise stated). Whenever possible,

    photos will be in 640x480 jpg files. Contractor agrees to include the loan and work order number in the subject of e-mail or on back of all hard copies.

    d.) Contractor agrees to maintain a photo history for at least 30 days from date photo was taken for all digital photos. e.) Only requested photos will be billed, and only good quality photos will be provided.

    By signing below contractor agrees to abide by this Service Level Agreement ________________________________________________ _________________________________ Independent Contractor Signature Date Please Print Name: ____________________________________ City, State, Zip: _______________________________________ Company Name: _________________________________________________________________________________

    file:///mailto:[email protected]

  • Page 9 of 9

    NFR Independent Contractor Application Packet 

     

    The NFR Independent Contractor Application Packet contains five forms:

      page 2 - 5         -     Background Information Form For Independent Contractor

      page 6         -     Independent Contractors Agreement

      Page 7         -     Independent Contractors Service Level Agreement

      Page 8         -     Independent Contractors Privacy Agreement

      Page 9         -     W9

     

    To submit your NFR Independent Contractor Application you need to complete the following two steps:

    1.         Please fill out, on your computer, the "Background Information Form For Independent Contractor" on pages 2 through 5 in this packet. When you are done, please click on the "Submit by Email" button on the bottom of page 5 and follow the instructions.

    2.         Please print out, fill out and sign pages 6 through 9 of this packet, which contain the "Independent Contractors Agreement", the "Independent Contractors Service Level Agreement", the "Independent Contractors Privacy Agreement" and the "W9". When you are done, please mail, fax or email the completed forms to us.

     

    When we have received all this information we can process your application.

     

    We look forward to working with you!

    S:\Logos\Martopia\NFR_logos3\NFR-002_final.jpg

    National Field Representatives, Inc.Contractor Services DepartmentPO Box 1440Claremont, NH 03743

    Phone         800-639-2151 ext. 243Fax         603-543-0412Email         [email protected]

    Background Information Form For Independent Contractor

    Emergency Contact:

    S:\Logos\Martopia\NFR_logos3\NFR-002_final.jpg

    Personal Information:

    Phone Numbers & Email:

    Page 2 of 9

    Instructions:

    1.         All fields marked with an asterisk (*) are required.

    2.          We need three references (page 5) in order to process your application.

    3.          The correct entry of zip codes (page 5) is very important. We assign work to contractors based on this information. You may enter a single zip code, a range of zip codes, or a list of zip codes and you may combine all of these styles. See the examples above the zip code entry boxes for details.

     

    Tip 1:          Review the form and collect all your data elements before you start. This may save you a lot of time.

    Tip 2:          You may save your application at any time, so you can come back to it later.

    Tip 3:         We highly recommend that you print and file a copy of your filled in form for future reference and save your completed form to your computer.

     

    Please enter phone numbers as 10 digits only; do not use dashes, spaces or parenthesis

    Property Preservations:

    How do you control quality?*

    General Information:

    Please describe your background in business in general, and in field services:

    Inspections:

    If you perform inspections, please provide us with your pricing information:

    Page 3 of 9

    Page 4 of 9

    Insurance:

    Please describe any court issued judgements you have had against you:*

    Please describe any insurance claims you have had in the last 3 years:*

    Please describe any felonies you, or any other principals, have ever been charged with:*

    Employees:

    If you do not carry Workers Comp, please explain why not?

    What zip codes do you propose to cover for NFR?

     

    Please enter zip codes that you cover on a routine basis in by using the following formats:

       Single zip         -   03743

       Range of zips         -   03743-03849 (to indicate that you will cover all zips in between and including 03743 and 03849)

       Range of zips         -   037 (to indicate that you will cover all zip codes starting with 037)

       List of zips         -   03001,03743,03601

       List of zips         -   03001,03601-03694,037 (to combine single zips and ranges)

     

    A minimum of one zip code in either the Inspection or Preservation catagory is required.

    Inspection

    Preservation

    Click on this button to automatically email your application to NFR

    ZIP Codes:

    Please list three references utilizing companies for whom you are currently providing services, preferably field services. A minimum of three is required.

    Company Name

    Contact Name

    Phone

    Reference 1*

    Reference 2*

    Reference 3*

    References:

    Page 5 of 9

    Ext.

    Page 6 of 9

    WHEREAS,                                             (hereinafter "Contractor") has agreed to periodically and from time to time provide services to National Field Representatives, Inc. (hereinafter "NFR") in reference to inspection, field work, property preservation and other activities assigned by NFR; and, 

    WHEREAS, the parties wish hereby to establish their legal relationship, duties and responsibilities;

    NOW THEREFORE, upon adequate consideration the receipt of which is hereby acknowledged, the parties hereby agree as follows:

    1.         The parties agree that Contractor shall serve as an independent contractor, and not as an employee or other agent or servant of NFR or its customers.

    2.         The parties agree that Contractor possesses such knowledge and expertise in field service, inspections, property preservation and related work that the parties rely upon Contractor utilizing said knowledge and expertise in the independent performance of duties assigned to Contractor by NFR.

    3.         Contractor agrees to undertake any and all work, if any, assigned to and accepted by Contractor in a prompt, professional, and expeditious manner, in full and complete compliance with all applicable law, FDCPA, governmental regulation, investor regulations, and in compliance with the time standards established by NFR.

    4.         Contractor shall solely be responsible for any and all taxes or other governmental payments due and payable from Contractor as a result of any and all monies earned by Contractor as an independent contractor of NFR.  NFR shall not withhold any such funds from payments made to Contractor, and Contractor agrees to accept responsibility to properly file any and all tax reporting and tax payments required of him in reference to said income.          

    5.         The parties acknowledge that NFR will provide tax reporting of said income to the Internal Revenue Service and any state or local taxing authority upon the basis of a 1099 form, on an annual basis or during such periods as is required by law.

    6.         The parties acknowledge that Contractor, as an independent contractor is not entitled to worker's compensation, disability, medical, retirement or any other benefits.

    7.         The execution and performance of this Agreement shall not constitute an employment contract, an agreement to continue use of the services of Contractor, or any other obligation in reference to continuation of the use of the services of Contractor by NFR.  NFR is under no obligation whatsoever to assign job or work to Contractor.  Either party may terminate this agreement at will, with or without cause, at any time, upon written notice to the other.  The Agreement shall be construed under the laws of the State of New Hampshire.

    8.         In the event of a dispute between the parties, jurisdiction shall vest solely in the courts of Sullivan County, State of New Hampshire.  Contractor assents to personal jurisdiction thereof.

     

     

    Date:                                    Independent Contractor Signature:

     

     

                                                 

    Please Print:  Name: 

     

                       Company Name:

     

                       Address:

     

                       City, State Zip:

     

     

    S:\Logos\Martopia\NFR_logos3\NFR-002_final.jpg

    Independent Contractor Agreement

    Page 7 of 9

    To: National Field Representatives, Inc.PO Box 1440Claremont, NH 03743

    Please Print:Name:__________________________________________(We, us)

    Company Name:_______________________________________________________________

    Address_______________________________________________________________

    City, State Zip_______________________________________________________________

    We provide certain services to you. In order for us to provide those services, you provide us with or you have provided us access to certain confidential information, including but not limited to mortgagor name, address, phone number, loan number, principal balance, monthly payments, default status, employment information, tenant/rent rolls and other information.

    We agree to not disclose to any other party the confidential information you provide to us, except as needed to employees and/or subcontractors to perform the services we have agreed to provide to you.

    We agree to only use the information to perform the service(s) we have agreed to provide to you.

    We agree to not use such confidential information for any purpose other than the specific business purpose for which it is furnished to National Field Representatives Inc.

    We agree to keep your customers’ information in our possession secure.

    We agree to protect against any anticipated threats or hazards to the security or integrity of such information.

    If the security of customer information is breached or in any way compromised while under our control, we agree to immediately notify you in writing and will take all steps practicable to minimize the harmful effects of the compromise.

    We agree that our obligations hereunder shall survive without limitation the expiration or termination of the Agreement be either party for any reason.

    Date: ___________________Independent Contractor Signature: ___________________________________________

    S:\Logos\Martopia\NFR_logos3\NFR-002_final.jpg

    Independent Contractor Privacy Agreement

    Page 8 of 9

    INDEPENDENT CONTRACTOR SERVICE LEVEL AGREEMENT

    This Service Level Agreement covers field inspection and/or property preservation

     services provided by undersigned contractor to

    National Field Representatives, Inc. (NFR) 

     

    1.         SERVICES 

    Contractor shall perform all requested and accepted orders in a professional workmanlike manner consistent with generally accepted industry standards. Contractor agrees to accurately complete information and services requested pursuant to each order and return results within the pre-determined time requirement. Contractor further agrees to be accessible to NFR for necessary follow-ups, status, updates, questions, etc. Communication and customer service will be regarded as an important requirement to fulfill. Contractor communication will be directed to the NFR coordinator shown on the order or any available team member.

     

    2.         INSPECTIONS 

    a.)         Contractor agrees to fulfill instructions and time service requirements for all inspections. Regular property inspections (PI), interviews & inspects (I&I), 24 hr rushes (24HR), insurance loss (IL), 3 day rushes (3 DAY), 5 day rushes (5 DAY), sale date (SD), retail outlet verifications (ROV), special occupancy (SPOCC), construction status (CS), redemption expiration (RED EX) realtor care (RC), Commercial (COMM), REAC etc.  have individual instructions as well as a due date noted on each request. Items returned incomplete or not within this time frame may be subject to being reduced to the next applicable pricing tier or no charge unless a specified exception is agreed by NFR. 

    b.)         Contractor agrees to promptly report to NFR if damages, violations, dangerous, or unusual conditions are found at any property.

    c.)         Contractor agrees that all first time vacancies will be returned to NFR within 1 business day of the inspection date.          

    d.)         It is agreed that inspection cancellations can be undertaken at any time. If said inspection has already been completed upon receipt of cancellation notice the normal inspection charge will be applied. If inspection is not completed at time of cancellation the inspection order will be disregarded.

    e.)         Contractor agrees to attempt contact with the owner, manager, and/or general contractor within 24 hours of receipt of an Insurance Loss Inspection order to schedule an appointment to meet at the property. Contractor agrees to promptly update the NFR coordinator of agreed inspection date and time. If contact cannot be made the contractor agrees to update NFR with this information. 

    f.)         Contractor agrees to promptly submit invoices after all required documents and required photos have been received and accepted by NFR. Contractor further agrees to submit invoice within 15 days of the inspection date. Invoice will include NFR's customer name (Mortgage Co.), loan number, inspection type, inspection date and agreed fee. NFR will not be obligated to pay any inspection invoices received more than 45 days after completion of the inspection. 

     

    3.         PRESERVATION 

    a.)         Property preservation will be completed within 3 days of receipt of the order unless otherwise indicated. A complete and legible Property Condition Report (PCR) will be submitted within 1 business day of completion of the order.

    b.)         Contractor agrees to have a full working knowledge and understanding of investor guidelines. Contractor further agrees to follow all expressed instructions in their entirety as shown on the NFR order.  Contractor agrees that conventional loans will be charged at FHA pricing. 

    c.)           Preservation trip charges will only be applied if contractor is unable to complete work on site for reasons beyond contractor control. 

    d.)         Contractor agrees to promptly submit invoices after all photos and required documents (i.e. dump receipts & city violations) have been received and accepted by NFR. NFR will not be obligated to pay any preservation invoices received more than 14 days after completion of the work.

    e.)         Contractor agrees to resolve invoice issues and or supporting documentation problems within 3 business days of notification of the problem. 

     

    4.         PHOTOS 

    a.)         Contractor agrees to follow photo instructions outlined in the inspection or preservation orders.

    b.)         Contractor agrees to submit all required photos with or prior to submission of invoice. 

    c.)         Digital photos will be sent 1 property per e-mail to: [email protected] (unless otherwise stated). Whenever possible, photos will be in 640x480 jpg files. Contractor agrees to include the loan and work order number in the subject of e-mail or on back of all hard copies. 

    d.)         Contractor agrees to maintain a photo history for at least 30 days from date photo was taken for all digital photos. 

    e.)         Only requested photos will be billed, and only good quality photos will be provided. 

     

    By signing below contractor agrees to abide by this Service Level Agreement

     

    ________________________________________________                                       _________________________________             

                    Independent Contractor Signature                                                                        Date

     

    Please Print         Name: ____________________________________          City, State, Zip: _______________________________________

             

                      Company Name: _________________________________________________________________________________

    ..\..\..\Documents and Settings\Robert\Desktop\w9.gif

    Page 9 of 9

    FirstName: LastName1: LastName2: CompanyType: MailAdd1: MailCity: MailSt: MailZip: ShipAdd1: ShipSt: ShipZip: ShipAddIsMailAdd: falseShipCity: WorkPhone: HomePhone: FaxPhone: FaxAvailable24Hours: falseCellPhone: BeeperPhone: ContactMemo1: ContactMemo2: EmailAddress: RepInspPrice4: RepInspPrice21: RepInspPrice22: RepInspPrice9: RepInspPrice12001: RepInspPrice23: RepInspPrice24: RepInspPrice10001: RepInspPrice55: RepInspPrice9999: BusClassNumber: ControlQuality: NAMFSMember: ASHINACHIMember: BackgroundInfo: WorkOrderDisc: YearsInBusiness: RepInspPrice1: DoesInsp: DoesWO: ComplyGuidelines: CompletedLeadCourse: BusClass: InspectorID: WhyNoWorkersCompMemo: Felonies2: GL_Comments2: Auto_Comments: InsClaims3Years2: CourtJudgements2: GL_Carrier: GL_Additional: HowManyEmployees: HowManyWorkersComp: Subs_Do_Both: InspZips: WorkZips: WorkZipsSameAsInspZips: falseEmailSubmitButton1: ReferenceComments2A: ReferenceComments1A: ReferenceComments1B: ReferenceComments2B: ReferenceComments3B: ReferenceComments1C: ReferenceComments2C: ReferenceComments3C: ReferenceComments3A: ReferenceComments1D: ReferenceComments2D: ReferenceComments3D: