Contractors Insurance Quote Request CONTRACTORS Complete Supplemental Questionnaire Applicant* Is the questionnaire for New business Renewal business Mailing Address* If renewal give current policy number INSURED 1. When did the applicants Business Start? 2. How long the applicant been in this line of work 3. Is or has the applicant ever been involved in any other business venture as an owner or officer yes no Explain 4. Has this business or any other business in which the insured is or was involved as an owner or officer ever declared bankruptcy yes no Explain 5. What classes of contractors licenses does the applicant hold 6. License Numbers(s) Does the applicant retain job files yes no How long are these files retained 7. List the owners, partners or officers of the applicants business Full Name Birth Date Title Time with this business EMPLOYEES 1. Provide the following informations concerning employees for the past three years and give an estimate for next 12 months. Year no of Full-time no of Part-time Number of seasonal employees Estimate 2. Describe the training programs used for employees 3. The applicant is Union non-union Open shop PAYROLL AND RECEIPTS Provide the following informations for the past three years (use audited information if possible) and give an estimate for the next 12 months Year Total receipts Payroll (excluding owners, partners and officers) $ $ $ $ $ $ Estimate OPERATIONS 1. Describe the last 5 projects completed (nature of work ,job length, dollar size etc). Any habitational projects in past 5 years? if so what? List general contractors for whom you obtained an additional insured endorsement on these projects 2. Is the applicant a general contractor yes no 3. Are any of the applicants employees qualified by education or licensed as architects, engineers, surveyors, draftsman or realestate agents / brokers yes no Explain the duties of each of these employees 4. Does the applicant offer any type of warranty yes no Explain 5. Does the applicant intend to expand the business operations in the next year yes no Explain 6. What is the radius of the applicants working area? Which states does this include? 7. Has the applicant performed other types of construction in the past? yes no Explain 8. What is the approximate breakdown of the applicants work %Commercial %(Repair remodelling) %=100% % Industrial %(Repair remodelling) %=100% %Habitational %(Repair remodelling) %=100% If habitational new construction Multi family incl. Apts, Condos, townhomes Custom Single Family Tract Housing / Large development Single-Family 9. Has the applicant been involved with OCIP / Wrap-up projects yes no Explain 10. Does the applicant currently do or has the applicant everdone any of the following? yes no Aircraft/Airports yes no Projects at a hazardous/toxic waste sites yes no Alarm Installation or service yes no Irrigation projects yes no Apartment/Condo projects (new) Projects involving systems or equipment that use LP gas as an energy source yes no Under 20 units yes no Projects involving work in mines,oil fields or other related energy fields yes no 20 to 39 units yes no Pollution cleanup yes no 40 or more units yes no Projects at power plant yes no Asbestos(including any attempted removal or covering) yes no Rail roads yes no Boats yes no Retaining walls yes no Boilers-high pressure(over 15psi) yes no Right of ways yes no Boilers-Low pressure yes no Roofing(in the past three years) yes no Bridges yes no Sewer mains yes no Demolition projects yes no Spray painting yes no Digging,grading or excavation yes no Security or alarm systems yes no Digging next to foundation or structures yes no Street or road paving yes no Drainage projects yes no Street or road subsurface work yes no Electrical power lines yes no Street or traffic lights yes no Use any explosives yes no Swimming pool yes no Exterior insulation and finish systems yes no Tract housing yes no Fireplace or wood stove installation or service yes no Tunneling yes no Fire proofing yes no Underwater work yes no Flood control projects yes no Water damage restoration or cleanup yes no Gas Lines yes no Water mains yes no Projects including hazardous/toxic waste yes no Work in trenches or tunnels yes no Mold Remidiation yes no If yes Explain SUBCONTRACTING AND SUBCONTRACTED WORK 1. Does the applicant hire subcontractors yes no 2. What type of operations does the insured subcontract out 3. Does the applicant require a certificate of insurance from subcontractors yes no Is a minimum limit of liability requires yes no what limit 4. Does the applicant ask to be named as an additional insured on the subcontractors general liability policy yes no 5. What is the total cost of subcontracted work on an annual basis LOSS CONTROL 1. Describe the applicants loss control or safety program 2. Does the applicant require an employment application to be completed by prospective employees yes no 3. Does the applicant obtain MVRs for new employees yes no 4. Does the applicant obtain pre-employment physicals for new or prospective employees yes no 5. Does the applicant always check with all local utilities before digging yes no CLAIMS OR LAWSUITS 1. Have there ever been any claims made or lawsuits filed against an applicant as a result of their contracting operations yes no 2. Have there ever been any claims made or lawsuits filed against an applicant as a result of alleged breaches of warranty in relation to work performed by the applicant yes no 3. Are there any known or apparent claims pending or potentially pending against the applicant as a result of contracting operations,including allegations of breach of warranty in relation to work performed by the applicant yes no 4. Are there any lawsuits pending or potentially pending against the applicant as a result of contracting operations,including allegations of breach of warranty in relation to work performed by the applicant yes no 5. Explain all "yes" answers to these questions       Comments (include any additional information which may assist the underwriter in evaluating the applicant) Please type the code shown*          Copyright © 2007 [Directory One, Inc.]. All rights reserved Site designed by "Innovative Tech Services Inc."