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
*
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