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Full Name of your Business Entity:

Assumed Business Name:

Business Address (physical):

* * *

Business Address (mailing):

* * *

Phone:

Fax:

Email:

Website:

Annual Gross Sales Volume:

Additional Locations Information:

Location 1:

Location 2:

Location 3:

Location 4:

Location 5:

Name(s) of Corporate Officer(s) or Principle(s):

Corporate Officer/Principle:

Marketing:

Training/Operations:

Office Manager:

City or State license(s) held:

Number of years your organization has been in business:

State where your company is registered:

Company Certifications* (check all that apply)
IICRC Certified Firm ASCR member Other

Company Certifications (check all that apply)
AMRT ASD CCT HST OCT SRT UFT
WRT Vortex Drying Dri-Zone CR Hydro-Lab
WLS IAQA

* ASD and/or Vortex Drying Certifications are required.

Current IMACC™ Member Reference(s) Name:

Is your company a member of the Better Busines Bureau?

YES NO

Is your company a franchise?

YES NO

If yes, please describe:

EQUIPMENT:

# of standard vans
# truck mount cubes
# box trucks
# pickup trucks
# of Hydro-X's
# of portable extractors
# of Water Claws

# of air movers
# of dehumidifiers (standard)
# of dehumidifiers (LGR)
# of portable desiccants
# of trailer dessicants
# of Water Out trailers
# of Hepa Vacs
# of HEPA air scrubbers
# of Injectidry's

Other extraction Equipment:

Insurance Information:

General Liability:

Contractors Pollution Liability:

Worker's Comp:

Automobile:

Volume:

Year	% Residential Jobs	% Commercial Jobs	Largest Single Job	Average Job Amount

Employee Information:

Current # of Employees

Do your employees wear uniforms? Yes No

Do your company vehicles have logos? Yes No

Do your employees carry proper identification? Yes No

Percentage of mitigation services rendered by subcontractors:

Local Bank Affiliation:

Bank Name:

Address:

* * *

Contact:

Names of three (3) primary insurance companies you work with on a regular basis:

Company Name :

Contact Name:

Phone Number:

Company Name :

Contact Name:

Phone Number:

Company Name :

Contact Name:

Phone Number:

Insurance Companies that your company currently participates in Preferred Vendor Programs:

Emergency Service Contact Info:

Pager:

Email:

Fax:

Cell Phone w/text address:

AREA(s) OF SPECIALTY (Check all applicable areas)

General Contractor:

Residential
Commercial

% subbed out:

Cleaning:

Carpet Cleaning
Content Cleaning
General Cleaning
Maid Services

% subbed out:

Water Mitigation

Commercial Mitigation
(24 Hour Service)
Residential Mitigation
(24 Hour Service)

% subbed out:

Smoke & Fire Mitigation

Board Up
Ozone
Pack Out
Security

Structure Cleaning
Temporary Fencing
Temporary Utility Service

Dry Cleaning

Electrical & Wiring

Electrical

Flooring

Carpet
Tile Work

Vinyl
Wood

Plumbing

Leak Detection
Plumbing

Roofing

% subbed out:

Siding

Aluminum
Hard Board
Hardi-Plank/Lapboard

T-111
Vinyl

Specialty Services

Asbestos Abatement
Earthquake Retrofit
Cabinets

Furniture Refinishing
Catastrophe
Mold Remediation

Window & Door

Door
Windows & Glass

Emergency Service 24/7

Yes
No

Emergency Service # :

Software you currently have and use:

Xactimate
JPP

POI
Simsol

States Served:

Counties Served:

Zip Codes Served:

An application fee of $350 must be received with your application.

By signing this Application for IMACC™ Membership you understand that you are allowing IMACC™ to do all acts necessary to investigate your organizations eligibility for membership including but not necessarily limited to a credit check through any nationally recognized credit reporting agency, security background checks through your local law enforcement agency, financial background information report from your bank institution and personal background check regarding the quality of services you have rendered in the past.

I, *, Corporate Officer/Owner of * swear under the penalty of perjury that the information supplied to IMACC™ in this Request for Application is true and accurate. I further authorize IMACC™ to investigate those areas of information disclosed immediately above and any other area they, in their uncontrolled discretion, feel necessary to approve our application for membership into IMACC™. I further state I am over the age of 18 and am qualified to make the representation contained in this Application.

* Corporation
by: * date