CONTRACTORS QUESTIONNAIRE
1a. Name of Broker:
1b. Broker Contact:
1c. Phone #:
1d. Email:
1e. Named Insured:
1f. Insured Adress
1g. City
1i. State
1j. Zip
2a. Separately list all Named Insureds and operations of each.
2b. Is or has insured been involved in any joint ventures or partnerships not described in
2a.
 Yes No
  If "yes", explain
2c. Number of years in business years
3.. Percentage of Operation as  
  General Contractor %
  Sub-contractor %
  Owner/ Builder %
4 Does the insured perform contracts that require bonding?
 Yes No
  If yes, who is the bond carrier and what is their bond line?
5. Describe the types of projects in which the Insured specializes
6. Describe any other projects, which the Insured has performed in the past 5 years
7. Does the Insured do any work over two stories in height from grade? Yes No
  If yes,  
  Maximum stories
  Percentage of work %
8. Does the Insured do any work below grade? Yes No
  If yes,  
  Maximum depth
  Percentage of total work %
9. Does the Insured have any operations other than the contracting? Yes No
  If yes, explain
10

Indicate the anticipated percentage of construction work over the next twelve months to be performed by the Insured using percentage of payroll under “Direct” and percentage of contact costs under ‘Subbed’ as the basis.

  Direct Subbed
Asbestos Removal
% %
Blasting % %
Bridge (Building) % %
Carpentry % %
Concrete % %
Demolition % %
Drilling % %
Electrical % %
Excavating % %
Grading % %
Insulation % %
Lead (Paint Removal) % %
Maintenance % %
Masonry % %
Mechanical % %
Painting % %
Plastering % %
Plumbing % %
Roofing % %
Sewer (Mains) % %
Steel (Structural) % %
Street/Road % %
Supervisory (Only) % %
Water/Gas (Mains) % %
Other (Describe below) % %
 
11. Estimated Annual Direct Payroll $
  Sub-contract Costs $
  Gross Receipts $
12
Prior Years ’06-07 ($) ’05-06 ($) ’04-05 ($) ’03-04 ($) ’02-03 ($)
Direct Payroll
Gross Receipts
13.

Indicate the percentage of construction work performed by the Insured

New Construction
 %
Remodeling %
Commercial %
Residential %
Inside Bldg %
Outside Bldg %
Other (Describe below) %
 
14.

List each state that the insured anticipants working in over the next year and % of receipts:

State
 %
%
%
%
%
%
%
15. Is there a general contract between Insured and project owner: Yes No
  If no, provide explanation
16. Are subcontractor agreements required for all subcontractors? Yes No
 

If yes, provide copy of subcontract agreement.
If no, provide explanation
LOSS CONTROL
17 Does the account have a job site Loss Control Program with the following provisions?
a. Written L.C. Program Yes No
b. Pre-Planning Meeting Yes No
c. Safety Meetings Yes No
  Attendance documents Yes No
d. Site Safety Inspection Yes No
  Check List Yes No
e. Non-compliance notice Yes No
  Safety violations Yes No
  Public safety hazards Yes No
f. Accident Reporting System Yes No
g. “Right to know” Yes No
  MSDS sheets on site Yes No
  Training sessions Yes No
  Please provide a copy of the index page of the written safety program.
AUTOMOBILE
18. Are company vehicles taken home by employees in the evening? Yes No
19a. What is the insureds policy regarding personal and family use of company vehicles? Yes No
b. Do they review Motor Vehicle Records on prospective employees and then annually thereafter? Yes No
c. What other criteria does the insured have for selecting new drivers? (e.g., written test)
d. Does insured have specific criteria to determine acceptable/unacceptable-driving methods? Yes No
  Explain
e. How does insured handle employees with unacceptable driving records i.e. driving privileges written warning, probationary period etc.?
20.

Please include the following items when returning this questionnaire:

  • Completed Acord applications for lines of business to be quoted
  • Copy of current subcontract agreement including insurance & indemnification requirements
  • Copy index page (Table of Contents) of the written safety program
  • 5 years currently valued, hard copy loss runs with details of all claims $25,000. or more
  • Current audited financial statement
  • Work on Hand Schedule, including start & anticipated completion dates, contract costs, location of projects, description of work being performed and percentage of work completed
  • Major projects completed within the last five years
  • If Automobile coverage has been submitted
    • MVRs for ALL drivers of company vehicles
    • Legible copies of registrations for all NY vehicles
     
  Name of Producer
  Name of Applicant Principal Officer
  Date
     
I have read and agree with the terms above.
I agree.
  Your e-mail address
  Your comments