Contractor Application Form

This form is to be completed by each contractor who intends to bid for work that is assisted through the LIHP Housing Rehabilitation Program.  Satisfactory completion of this form enables you as a contractor to be placed on the list of Available Contractors, that LIHP staff will distribute to eligible homeowners who are ready to invite bidders.  Copies of current Nassau or Suffolk County Home Improvement Licenses and proof of insurance must be attached to this form.  Please note that for the rehabilitation work in the towns of Southampton, East Hampton, Shelter Island and Mastic Beach Village a locally issued contractor's license is required.
I. General Information

Contractors must attach evidence of licenses that are required by local governments.  Our program also requires contractors to carry the following insurance coverage:
(NOTE:  Attach proof of insurance and current license to this form using "Select File" upload button below.)

A. Comprehensive General Liability Insurance

a. Bodily injury $1,000,000 each occurrence

b. $2,000,000 general aggregate

c. $5,000,000 umbrella policy

B. Comprehensive Automobile Liability

a. $1,000,000 include coverage for hired and non-hired vehicles

Attach Proof of Insurance, Current License(s), Certificate of Worker's Compensation Insurance and  RRP Certificate files here:
(Click Select File to Upload for each file to be uploaded)

II. Areas of Expertise


Please indicate the years of experience you have in any of the areas below:
Type of Work

List your three most recent jobs completed:

I authorize the LIHP program administrators to verify the above information and I certify that the above information is true and complete:

Contact Information