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Contractors Questionnaire

Contractors Questionnaire

Contractors QuestionnaireDealership Insurance Services2023-08-25T16:56:18-04:00

"*" indicates required fields

Step 1 of 8

12%

Business Owner's Name*

First Last

Email*

Phone*

Legal Business Name*

Years in business under current business name*

Business Address*

Street Address Address Line 2 City State ZIP Code

Please briefly describe business operations

Do you have other business operations active or inactive?*

Yes

No

Please explain other operations

Contractors License #*

State(s) in which you do business*

Have you had any other business names & licenses in the past 10 years?*

Yes

No

List business names and licenses*

What were the operations?*

Do you currently own/operate any other business?*

Yes

No

Please provide the business name(s) and percentage of ownership

Please describe other business operations

Current Operation Percentages

Please enter 0 below if an operation does not apply.

General Contractor %*

Subcontractor %*

Construction Manager %*

Do you use Subcontractors?*

Yes

No

Percentage of subcontracted work*

Annual subcontracting cost*

(including all of subs' labor and materials)

Do you collect certificates from all subcontractors?*

Yes

No

What is the limit required from these subcontractors?*

Payroll Estimates

Estimated payroll for the next 12 months. All fields are required. Please enter 0 if no payroll.

Payroll*

Subcontractor Cost*

Gross Receipts*

5 Years Prior History

Last Year Payroll*

Last Year Subcontractor Cost*

Last Year Gross Receipts*

2nd Year Payroll*

2nd Year Subcontractor Cost*

2nd Year Gross Receipts*

3rd Year Payroll*

3rd Year Subcontractor Cost*

3rd Year Gross Receipts*

4th Year Payroll*

4th Year Subcontractor Cost*

4th Year Gross Receipts*

5th Year Payroll*

5th Year Subcontractor Cost*

5th Year Gross Receipts*

Construction Performed By You

New Construction (Residential)*

Please enter a number from 0 to 100.

New Construction (Commercial)*

Please enter a number from 0 to 100.

Remodeling/Repair (Residential)*

Please enter a number from 0 to 100.

Remodeling/Repair (Commercial)*

Please enter a number from 0 to 100.

Other (Residential)*

Please enter a number from 0 to 100.

Other (Commercial)*

Please enter a number from 0 to 100.

Construction Total

Estimated Types of Construction Work to Perform

Please enter the estimated percentage of construction work to be performed over the next 12 months using payroll Direct and Subcontracted.

Airports (Direct)

Please enter a number from 0 to 100.

Airports (Subbed)

Please enter a number from 0 to 100.

Blasting (Direct)

Please enter a number from 0 to 100.

Blasting (Subbed)

Please enter a number from 0 to 100.

Bridge Building (Direct)

Please enter a number from 0 to 100.

Bridge Building (Subbed)

Please enter a number from 0 to 100.

Carpentry (Direct)

Please enter a number from 0 to 100.

Carpentry (Subbed)

Please enter a number from 0 to 100.

Concrete (Direct)

Please enter a number from 0 to 100.

Concrete (Subbed)

Please enter a number from 0 to 100.

Demolition (Direct)

Please enter a number from 0 to 100.

Demolition (Subbed)

Please enter a number from 0 to 100.

Drilling (Direct)

Please enter a number from 0 to 100.

Drilling (Subbed)

Please enter a number from 0 to 100.

Drywall (Direct)

Please enter a number from 0 to 100.

Drywall (Subbed)

Please enter a number from 0 to 100.

Earthquake (Direct)

Please enter a number from 0 to 100.

Earthquake (Subbed)

Please enter a number from 0 to 100.

Electrical (Direct)

Please enter a number from 0 to 100.

Electrical (Subbed)

Please enter a number from 0 to 100.

Excavation (Direct)

Please enter a number from 0 to 100.

Excavation (Subbed)

Please enter a number from 0 to 100.

HVAC (Direct)

Please enter a number from 0 to 100.

HVAC (Subbed)

Please enter a number from 0 to 100.

Grading (Direct)

Please enter a number from 0 to 100.

Grading (Subbed)

Please enter a number from 0 to 100.

Insulation (Direct)

Please enter a number from 0 to 100.

Insulation (Subbed)

Please enter a number from 0 to 100.

Maintenance (Direct)

Please enter a number from 0 to 100.

Maintenance (Subbed)

Please enter a number from 0 to 100.

Masonry (Direct)

Please enter a number from 0 to 100.

Masonry (Subbed)

Please enter a number from 0 to 100.

Mechanical (Direct)

Please enter a number from 0 to 100.

Mechanical (Subbed)

Please enter a number from 0 to 100.

Painting (Direct)

Please enter a number from 0 to 100.

Painting (Subbed)

Please enter a number from 0 to 100.

Plastering (Direct)

Please enter a number from 0 to 100.

Plastering (Subbed)

Please enter a number from 0 to 100.

Plumbing (Direct)

Please enter a number from 0 to 100.

Plumbing (Subbed)

Please enter a number from 0 to 100.

Roofing (Direct)

Please enter a number from 0 to 100.

Roofing (Subbed)

Please enter a number from 0 to 100.

Seismic/Retrofitting (Direct)

Please enter a number from 0 to 100.

Seismic/Retrofitting (Subbed)

Please enter a number from 0 to 100.

Sewer (Direct)

Please enter a number from 0 to 100.

Sewer (Subbed)

Please enter a number from 0 to 100.

Steel/Structural (Direct)

Please enter a number from 0 to 100.

Steel/Structural (Subbed)

Please enter a number from 0 to 100.

Steel/Ornamental (Direct)

Please enter a number from 0 to 100.

Steel/Ornamental (Subbed)

Please enter a number from 0 to 100.

Street/Road (Direct)

Please enter a number from 0 to 100.

Street/Road (Subbed)

Please enter a number from 0 to 100.

Supervisory Only (Direct)

Please enter a number from 0 to 100.

Supervisory Only (Subbed)

Please enter a number from 0 to 100.

Traffic Signals (Direct)

Please enter a number from 0 to 100.

Traffic Signals (Subbed)

Please enter a number from 0 to 100.

Water/Gas Mains (Direct)

Please enter a number from 0 to 100.

Water/Gas Mains (Subbed)

Please enter a number from 0 to 100.

Other (Direct)

Please enter a number from 0 to 100.

Other (Subbed)

Please enter a number from 0 to 100.

Projects

Describe your 5 largest projects over the past 5 years, including values*

List 5 current projects currently underway or planned for the next year, including values*

How many new homes will you build from the ground up in the next year?*

Please enter a number greater than or equal to 0.

Have you ever built a home from the ground up?*

Yes

No

How long ago?*

How many?*

Have you built, or will you build, on hillsides, terraces, landfills, or Subsidence areas?*

Yes

No

Please explain building*

Do you use scaffolding?*

Yes

No

Please explain scaffolding use*

Have you been involved, or will you be involved, with blasting operations or any other hazardous work activity?*

Yes

No

Please explain hazardous working activities

Do you perform synthetic stucco work (EIFS)?*

Yes

No

Do any of your subcontractors perform EIFS work?*

Yes

No

Have you, or will you, build/demolish buildings or structures in excess of 4 stories?*

Yes

No

Please explain demolishing work*

Do you perform work above 2 stories in height (other than interior remodel)?*

Yes

No

What Percentage?*

Max Height?*

Please Describe*

Do you perform work at airports?*

Yes

No

Explain airport work*

Do you own, rent, or subcontract any cranes?*

Yes

No

Explain cranes*

Have you been involved or will you or your subcontractors be involved in any removal of asbestos, PCB's or other hazardous materials?*

Yes

No

Removal or work on fuel tanks or pipelines?*

Yes

No

Do you or your subcontractors perform roofing work?*

Yes

No

Hot Tar?*

Yes

No

Torch Down?*

Yes

No

Hot Air Welding*

Yes

No

Hot Tar %*

Hot Air Welding %*

Modified Bituman (HOT)*

Yes

No

Modified Bituman (COLD)*

Yes

No

Roofing Other

Do you perform any Mold Remediation work?*

Yes

No

Do any of your subcontractors perform Mold Remediation work?*

Yes

No

Have you performed, or will you or your subcontractors, perform any work below grade?*

Yes

No

Maximum Depth (in feet)*

% of Operations*

Please enter a number from 0 to 100.

Any shoring, underpinning, cofferda, or caisson work?*

Yes

No

Explain shoring, underpinning, etc.*

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

Do you have a formal safety program in place?*

Yes

No

Will any work involve the construction of or involvement with Condominiums or Townhouses?*

Yes

No

Is condo work on New Construction or Repair or Remodel only?*

New Construction

Repair or Remodel only

Will any work involve the construction of or involvement with Apartments?*

Yes

No

Is apartment work on New Construction or Repair or Remodel only?*

New Construction

Repair or Remodel only

Number of units in the ENTIRE project*

Please enter a number greater than or equal to 0.

Will any work involve the construction of or involvement with new Duplexes, Triplexes, Fourplexes, or Patio Homes?*

Yes

No

Have you ever worked in new Condominiums/Townhouses?*

Yes

No

How long ago*

Have you ever worked in new Apartments?*

Yes

No

How long ago*

How many units in the entire building?*

Have you ever worked in new Duplexes, Triplexes, Fourplexes, or Patio Homes?*

Yes

No

How long ago*

Have you ever worked in new Tract Developments?*

Yes

No

How long ago*

How many units in the entire development?*

Any current Wrap-Up/OCIP Projects?*

Yes

No

Name of wrap-up Carrier*

Have you ever worked in new Assisted Living Facilities?*

Yes

No

How long ago*

How many units in the entire building?*

Have you, or will you, ever convert Apartments to Condominiums*

Yes

No

Any unusual exposures/operations not otherwise covered by this questionnaire?*

Yes

No

Please explain other exposures*

Additional Insured(s)

How many Additional Insured endorsements do you anticipate needing in the next year?*

How many Waivers of Subrogation do you anticipate needing in the next year?*

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

Has any other licensing authority taken any action against you?*

Yes

No

Losses and Claims

Are there any claims or legal actions pending against any of the entities?*

Yes

No

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 them?*

Yes

No

Have you been accused of faulty construction in the past 5 years?*

Yes

No

Have you been accused of breaching a contract in the past 5 years?*

Yes

No

Have you ever filed any Mechanic Liens in the past 5 years?*

Yes

No

Finish

Consumer Disclosure*

All the above statements made by me in this form are accurate and true to the best of my ability.

I Agree

Signature

Today's Date

MM slash DD slash YYYY

Comments

This field is for validation purposes and should be left unchanged.

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