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Business Name
*
DBA?
FEIN or SS#
Type
FEIN
SS#
Contact Name
What is your mailing address?
*
Phone number (format 123456789)
*
Email
*
Web Site URL:
Effective Date?
Annual Revenue:
$
Number of employees:
Annual Payroll
$
How many years in operation?
How many years have you been in this industry?
How is this business owned?
individual/sole proprietor
corporation
partnership
LLC
other
What types of insurance do you need?
business owners policy (BOP)
general liability (GL)
commercial property
commercial auto
excess liability
workers comp
Largest project completed in last 12 mths: description / length of project / cost / residential or commercial?
2nd largest project completed in last 12 mths: description / length of project / cost / residential or commercial?
3rd largest project completed in last 12 mths: description / length of project / cost / residential or commercial?
Largest project completed in last 5 yrs: description / length of project / cost / residential or commercial?
2nd largest project completed in last 5 yrs: description / length of project / cost / residential or commercial?
3rd largest project completed in last 5 yrs: description / length of project / cost / residential or commercial?
4th largest project completed in last 5 yrs: description / length of project / cost / residential or commercial?
Please Describe Operations
Type of Construction
Selected Value:
50
Residential vs Commercial
If building homes, how many per year?
If building apartments, how many per year?
Has the nature of your operations changed in the past 12 months?
yes
no
If YES, please describe the changes:
How many years have you performed this trade?
How many years have you been in the contracting business?
List all the states in which work is performed:
Have you ever been involved in litigation concerning defective workmanship?
yes
no
If YES, please describe:
Liability Hazard Information: Are all underground utilities clearly marked prior to digging operations? (If digging deeper than 3 ft, please request an Excavation Supplement) Do not answer if no digging performed.
yes
no
Are construction sites fenced? Do not answer if not relevant.
yes
no
Hot work: do operations involve the use of torches or heat processes for cutting, sweating, sealing or joining materials?
yes
no
If YES, what controls are used to control potential losses arising out of hot work?
Is scaffolding used on the job?
yes
no
Do you use scaffolding?
yes
no
Do any of your subcontractors use scaffolding?
yes
no
Who is responsible for installing scaffolding?
Applicant (you)
Contractor
Not Applicable
Do you test and/or inspect all scaffolds used?
yes
no
not applicable
Current insurance carrier & how many years with them?
*
Any specifics on limits and/or coverage?
*
Any commercial claims in last 5 years? (If YES, please list date, description and claim amount)
Do you do any landscape contracting?
yes
no
Do you do any excavation more than 3 ft deep?
yes
no
Notes
Subcontracting Information: do you use subcontractors?
yes
no
If no, you can skip to “Get Contractor Quote” at bottom of form
Percentage of work subcontracted out %
Annual Costs $
When selecting subcontractors, what criteria do you use? (check all that apply)
cost
references
prior experience
regular use
Do you require "additional insured" status on subcontractor's policies?
yes
no
Do you require the subcontractor to carry a limit of liability insurance at least equal to a specified amount?
yes
no
not applicable
If YES, what liability limits are required? $
When using subcontractors, do you use written contracts to establish the responsibilities and expectations of all parties involved including insurance requirements?
yes
no
not applicable
Do your written contracts contain indemnification agreements in your favor with all subcontractors?
yes
no
not applicable
Have the procedures listed above been followed for at least the past 3 years?
yes
no
Does your record keeping procedure include maintaining copies of contracts, certificates, additional insured endorsements and/or OCP policies for each job?
yes
no
If YES, for how long?
If subcontractors do not comply with the insurance provisions of the contract or your request for evidence of coverage (certificate, additional insured endorsement, etc), what means of enforcement are used?
evidence of subcontractor’s coverage is required prior to starting work
subcontractor is not permitted on work site
subcontractor is not paid until in compliance with insurance provision
not applicable
Of those subcontractors engaged, what percentage have you:
used regularly?
%
used occasionally
%
never used previously
Get Contractor Quote
