Applicant:

Name

First Last

Company

Entity type:

Corporation

LLC

Sole Proprietorship

Phone

Email

Website

Years in business under current name:

Describe your operations:

Do you currently have, or have you had in the past, a controlling interest in any other similar operations whether active, inactive or dissolved?

Yes

No

If yes, please describe:

Have you ever declared bankruptcy under this name or any other similar entity in which you have had a controlling interest?

Yes

No

If yes, please provide the name of each entity, and the date and jurisdiction of bankruptcy:

Contractor’s license number:

States in which you do business:

New York State Applicants: Any work in the five boroughs of New York?

Yes

No

All Applicants: Do you do any work in Colorado?

Yes

No

List all other business names & licenses applicant has used in the past 10 years:

Describe the operations:

Does applicant currently own/operate any other business?

Yes

No

If yes, please provide the name of the business and percentage of ownership:

Describe the operations:

Percentage of current operations:

General Contractor %:

Subcontractor %:

Construction Mgr %:

Do you use Subcontractors?

Yes

No

If yes, please complete the following:

Percentage of subcontracted work:

Annual subcontracting cost (including all of subs’ labor and materials: $

Describe all activities that are subcontracted. If you are a general contractor, describe the activities you do yourself:

Are there any circumstances when you do work for a general contractor that you use a subcontractor? If yes, please describe:

Subcontractors:

Do you collect certificates of insurance from all subcontractors?

Yes

No

What limits of coverage are required from these subcontractors?

Do you require all subcontractors to name you as an Additional Insured, including for Completed Operations, and is this part of the written contract?

Yes

No

Do you require all subcontractors to defend, indemnify and hold you harmless from their activities and is this part of the written contract?

Yes

No

Who reviews and maintains the certificates?

How long are they kept?

DEFINITIONS:

EIFS

Exterior Insulation Finishing Systems – means an exterior cladding or finish system used on any part of any structure and consisting of: a) a rigid or semi-rigid insulation board made of expended polystyrene or other materials; and b) an adhesive and/or mechanical fasteners used to attach the insulation board to the substrate; and c) a reinforced base coat; and d) a finish coat providing surface texture and color.

GENERAL CONTRACTOR

A contractor, who exercises primary control of the job site, typically subcontracts a significant portion of the work, and/or is named in the construction documents as the general contractor of record.

RESIDENTIAL CONTRACTOR

Single or multi-unit family housing, including apartments, condominiums and townhouses, planned unit developments and tract housing or similar planned communities.

SUBSIDENCE

Any movement of the land or earth including landslides, mudflow, earth sinking, rising and shifting, collapse or movement of fill, earth settling, slipping, falling away, caving in, eroding or tilting and earthquake.

TORCH APPLIED ROOFING (MODIFIED BITUMEN)

This process which is also called torch welding, involves a modified bitumen installed on a roofing deck by means of a torch. A membrane is laid on the roof, heated by a torch and allowed to cool so that the material solidifies in place. The asphalt component in the membrane serves as an adhesive between the surface material and roof substrate.

MODIFIED BITUMEN

Also called “modbit” membranes consist of an asphalt and polymer blend which allow the asphalt to take on characteristics of the polymer.

HOT AIR WELDING

Hot Air Welding is a system utilizing a heating source (either electric or propane flame) attached to a hose, which blows hot air onto the membrane.

TRACT HOUSING

Developments where the houses are similar in price, physical characteristics, lot size and square footage; numerous houses of similar or complementary design constructed on a given expense of land, by a single builder.

WRAP-UP (OCIP/CCIP)

A policy providing coverage(s) for all interests in a major construction project. Also know as an OCIP (Owner Controlled Insurance Program) or a CCIP (Contractor Controlled Insurance Program).

WARRANTY:

The purpose of this Contractors Questionnaire is to assist in the underwriting process. Information contained herein is specifically relied upon in determination of the applicant's insurability. Material misstatements or errors made on this form may provide a basis for the company's rescission of the policy at any time during the term of the policy, with the return of unearned premium. The undersigned, therefore, warrants that the information contained herein (consisting of 6 pages) is true an accurate to the best of his knowledge, information and belief. The Supplemental Questionnaire shall be the basis of any insurance policy that may be issued.