- Applicant:
- How
many years of experience do you have in the contracting
business?
Years in business of
entities seeking coverage?
- What Percentage of your work is : (each line
must add up to 100%)
a. (Residential) %
(Industrial) %
(Commercial) %
b.
(New Const) %
(Struct. Remodel/Additions)%
(Non-Structural Remodel)%
- What percentage of your work is as a:
General Contractor %
Subcontractor %
Construction %
- Do you use
subcontractors? Yes No If Yes, complete
the following:
a) Percentage of your work subcontracted
out %
Annual costs %
b) List the trades of the subcontractors you use and give the
percentage of work they perform:
%
%
%
%
% %
c) Do you collect certificates from all subcontractors? Yes No What limit:
d) Do you require all subcontractors to
name you as an additional insured? Yes No
If Yes, have you always done so?
e) Does your contract with subcontractors include a hold harmless
favoring you? Yes No
f) How long do you maintain
records of the above documents?
- Do you work outside
California? Yes
No
Describe:
- Gross receipts for
the past 4 years and the next 12 months:
4th year prior
3rd year prior
2nd year prior
Lasr 12 months
Next 12 months
- Number of owners, officers, and partners active at
job sites or performing supervisory duties:
- Describe your four
largest projects over the past five years, including values:
1.
2.
3.
4.
- Describe your two
largest projects currently underway or planned for the next year,
including values:
1.
2.
- Dollar value of average job completed (including all
materials, labor & equipment)
- A. How many new homes will you build as a general
contractor in the next year?
B.
What is the greatest number of new homes you have built in any one
year?
- Do any prior
operations differ substantially in nature from current
operations? Yes No
Please explain:
- Note : The following
question applies to work done in any capacity (including general
contractors, developers, artisans,
re-modeling contractors,
site work contractors, suppliers, etc. )
Have you or will you
perform work involving or related to or about the premises of:
a)
Condominiums or townhouses Yes No
b)
Apartments
Yes No
c) Tracts, PUD's or other development,
premises or project with more than 7 homes built or planned? Yes No
Please describe:
- Have you ever
performed work on hillsides, hill tops, slopes, landfill or other
subsidence areas or do you plan to in the
future? Yes No If yes maximum degree of slope?
Please describe:
- Have or will any of
your projects involve caissons, cantilevers, piers, retaining walls,
shoring , underpinning or other heavy
structural engineering
techniques? Yes No
Please describe:
If retaining walls have been or will be
built, maximum height:
- Do you perform work above two stories
in height ( other than interior remodeling)? Yes No
If so, what percentage? %
Maximum height: ft.
Please describe:
- Do you perform
any work below ground level? Yes No
If so, what percentage? %
Maximum depth? ft.
- Have you or will you
build, remove, repair or replace roofs? Yes No % Hot tar:
Please describe:
- Have you or will you
perform work for the following types of clients or industries: gas
stations, refineries, chemical plants,
airports, public utilities,
railroads or hospitals? Yes No
Please describe:
- Have you or will you work as a construction manager
on a fee
basis? Yes No
Have you or will you supervise subcontractors whose
payments are run through another entity? Yes No
Please describe:
- In the past 3 years have you been fired or replaced on a job in progress? Yes No
In the
past 3 years have you replaced another contractor on a job in
progress? Yes
No
Please describe:
- Note: The following
questions apply regadless of whether the applicant was at fault for a
claim or incident and regardless of
whether the claim or
incident was covered by insurance. Explain any "yes" answers in
the space provided below:
a) Have there been any loses, claims or suites
against you in the past five
years? Yes No
b) Are there any claims or legal actions
pending against any of the entities named in the application? Yes No
c) Do any of the entities named in the
application have knowledge of any pre-existing act, omission, event,
condition, or
damages to any person or property
that may potentially give rise to any future claim or legal action
against any such
entity? Yes No
d) Have you been accused of faulty construction in the
past 5 years? yes No
e) Have
you been accused of breaching a contract in the past 5
years? Yes No
- For each of the following activities, check:
Yes: If the activity has or will be performed, subcontracted
or supervised by applicant.
No : If the applicant has
never and does not plan to perform, subcontract or supervise the
activity
Explain any "yes" answers and state whether
performed by insured or subcontracted:
WARRANTY:
The purpose of the Supplemental Questionnaire is to assist the
underwriting process. Information
contained herein is
specifically relied upon in determination of insurability. The
undersigned, therefore, warrants
that the information is true and
accurate to the best of his knowledge, information and
belief. his Supplemental
Questionnaire, and the
application to which it is appended shall be the basis of any insurance
policy that may be
issued and will be part of such
policy.
Signature of Applicant:
________________________________________
Date :
Name
and Title : |