Contractors Questionnaire

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CENTURY INSURANCE GROUP CONTRACTORS QUESTIONNAIRE

CENTURY INSURANCE GROUP CONTRACTORS QUESTIONNAIRE

Note: this application must be completed in addition to the ACORD Applicant Information Section and the Commercial General Liability Applicatoin
GENERAL INFORMATION:
1. Applicant:
Years under this name:
2. Contractor's States and Liscense Numbers:
3. Percentage of operations:
General Contractor:
Subcontractor:
Owner/Builder:
Other(explain):
If Subcontractor - Specific Trade:
4. Estimates for next 12 months:
Employee Payroll by Class ($;Class)
Total number of employees:
Active Owner(s) Payroll:
Number of Active Owners:
Subcontractor Costs:
For the past three years:
First Prior (direct payroll;sub-contractor costs;gross receipts)
Second Prior (direct payroll;sub-contractor costs;gross receipts)
Third Prior (direct payroll;sub-contractor costs;gross receipts)
5. Do you have operations other than contracting? Yes No
Covered by other insurance? Yes No
If yes, please explain:
6. Do you keep records of certificates of insurance and contractual agreements with all subcontractors for at least ten years? Yes No
7. Have you worked or will you or your employees work under U.S. Longshoremen's and Harbor Workers' Act or Jones Maritime Act? Yes No
If yes, please explain:
WORK PERFORMED:
8. Do you do any EIFS (exterior insulation and finish systems) work or installation? Yes No
If yes, attach EIFS supplemet to qualify for claims made coverage. (note EIFS work will be excluded on occurrence based policies)
9. Do you have roofing operations? Yes No
If yes, please complete roofing supplement
10.a. Please provide the following split of your work:
Commercial/Industrial (%):
Residential (%):
10.b. Please Provide detail of your commercial and residential work (note that the commercial and residential percentages must equal 100%):
New Construction (% commercial; % residential):
Remodeling (% commercial; % residential):
Additions (% commercial; % residential):
Repair (% commercial; % residential):
Other (% commercial; % residential):
Total: 100%; 100%
If other, please describe category of work:
11. Have you, or will you, work as a construction manager on a fee basis? (note: if accepted all such work will be excluded from coverage) Yes No
Have you or will you supervise subcontractors whose payments are run through another entity? (note: if accepted all such work will be excluded) Yes No
12. Have you ever been involved or will you or any subcontractors be involved with blasting operations or hazardous or unusual work activity? Yes No
If yes, please explain:
13. Have you been involved or will you or your subcontractors be involved in any removal of asbestos, lead, mold, PCB's, or other hazardous material? Yes No
Removal or work on fuel or chemical storage tanks or pipelines? Yes No
14. Has or will any of your work involve(d) homes in tracts of greater than 10 homes, condominiums, apartments, or townhouses? Yes No
If no, all multi family residential work will be excluded - proceed to question 19. If yes, you must provide answers as requested to questions 15, 16, 17, and 18.
15. What is the total sales from ALL residential work referenced in question 14 above for the last three years:
Tracts of greater than 10 homes (1st prior year;2nd prior year;3rd prior year):
Condominiums (1st prior year;2nd prior year;3rd prior year):
Apartments (1st prior year;2nd prior year;3rd prior year):
Townhomes (1st prior year;2nd prior year;3rd prior year):
(If you have indicated tract homes, what is the maximum number of homes in a tract:
16. Is the work...
New construction - including additions? Yes No
Repair only? Yes No
If new construction, have you ever, do you currently, or do you intend to be involved in new construction (including site preparation) on the following?
Apartments (less than 26 units) Yes No
Apartments (26 units or more) Yes No
Condos (less than 16 units) Yes No
Condos (16 units or more) Yes No
Custom Homes Yes No
Townhouses (less than 16 units) Yes No
Townhouses (16 units or more) Yes No
Tracts (Single Family, less than 10 units) Yes No
Tracts (SIngle Family, 10 units or more) Yes No
Condo/Townhouse/Apt Repair only Yes No
17. If you have done any multi-family housing please indicate the following percentages of the following (total should equal 100%):
Senior
HUD
Low Income
Standard
18. Do you desire multi-family residential contracting operations to be covered by this insurance? Yes No
19. Have you performed or will you or your subcontractors peform any work below grade? Yes No
Maximum depth:
% of Operations:
20. Has your work involved or will it involve systems that provide...
Medical and/or industrial life support; process piping? Yes No
work on dams/levees? Yes No
If yes, please explain:
PREVIOUS WORK:
21. Describe any significant projects (accounting for more than 10% of total revenue any one year) which you have performed during the past five (5) years:
22. Have you built or will you build on hillsides, terraces, landfills, or subsidence areas? Yes No
If yes, please explain:
23. Have you built or will you build/construct buildings or other structures in excess of four (4) stories? Yes No
If yes, please explain:
SUBCONTRACTOR INFORMATION:
24. Have you allowed or will you allow your license to be used by any other contractor for a project on which you have worked? Yes No
25. Do you require subcontractors to name you as an additional insured and provide endorsement of same? Yes No
Limit required:
Written Contract? Yes No
If no, during the pendency of the policy to which this applicaiton is attached, do you warrant that adequate records of certificate insurance/additional insured endorsement and contractual agreements with subcontractors will be kept? Yes No
If yes, do you warrant that during the pendency of the policy to which this application is attached you will continue to keep adequate records of certificates of insurance/additional insured endorsement and contractual agreements with subcontractors? Yes No
SAFETY:
26. Indicate the type of security used on a project: Fencing Lighting Watchman
27. Do you or will you have a formal safety program in place? Yes No
PRIOR CARRIER:
28. List expiring carrier information for the past 3 years:
Expiring (Carrier;Limit$;Deductible;Premium;Special Exclusions;Form OCC or Claims Made):
1st Prior (Carrier;Limit$;Deductible;Premium;Special Exclusions;Form OCC or Claims Made):
2nd Prior (Carrier;Limit$;Deductible;Premium;Special Exclusions;Form OCC or Claims Made):
LOSS INFORMATION:
29. Loss History for the past five (5) years (Policy Year;Aggregate Losses;No. of Claims;Largest Single Loss;Comments):
1.
2.
3.
4.
5.
I hearby attest under penalty of perjury I have had no General Liability claims in the past five (5) years.
In the event that claims are discovered, for the period in question, our policy premium would be 100% fully earned and subject to cancellation, reformation, and/or revocation.
Insured's Signature:
Date:
30. Has any lawsuit ever been filed, or any claim otherwise been made against your company or any partnership or joint venture of which you have been a member of your company's predecessors in business? Yes No
Or against any person, company or entities on whose behalf your company has assumed liability? Yes No
If yes to either, please explain:
31. During the past five years, has any insurer ever cancelled, declined, or refused to issue similar insurance to any applicant? Yes No
If yes, please explain:
32. Is your company aware of any facts, circumstances, incidents, situations, damage or accidents (including but not limited to faulty or defective workmanship, product failure, construction dispute, property damage or construction worker injury)? Yes No
Might a reasonable prudent person expect any of these to give rise to a claim or lawsuit, whether valid or not, which might directly or indirectly involve the company? Yes No
If yes, please explain:
Notice: This application becomes part of the policy and must be signed in ink by the President or Owner of the Named Insured. Please read the following statement carefully before signing.
Any coverage we issue is due to the reliance of the truth and accuracy of the statements in this application.
The undersigned Applicant warrants that the above statements and particulars, together with any attached or appended documents or materials ("this Application"), are the true and complete and do not misrepresent, misstate, or omit any material facts.
Furthermore, the Applicant authorizes the Company, as administrative and servicing manager, to make any investigation and inquiry in connection with the Application as it may deem necessary.
The Applicant agrees to notify the Company of any material changes in the answers to the questions on this application which may arise prior to the effective date of any policy issued pursuant to this application.
The Applicant understands that any outstanding quotations may be modified or withdrawn based upon such changes at the sole discretion of the Company.
Notwithstanding any of the foregoing, the applicant understands the Company is not obligated nor under any duty to issue a policy of insurance based upon this Application.
The Applicant further understands that, if a policy is issued, this Application will be incorporated into and forms a part of such policy.
Signature of Applicant:
Date:
Title (Officer, Partner):
Signing this questionnaire does not bind the applicant or the insurer or the administrative and servicing manager to complete the insurance.
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