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Contractors Questionnaire
Home
Contractors Questionnaire
E&S Bonded and P&C Licensed
A Rated Insurers and Specialty Markets
Contractors Questionnaire
Sheldon Altschuler
2024-02-01T10:25:50-05:00
"
*
" 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
- Select -
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
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Email
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