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ARTISAN CONTRACTORS SUPPLEMENTAL QUESTIONAIRE (Colonial General Insurance Agency, Inc)

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P.O. Box 14770, Scottsdale, AZ 85267-4770 P.O. Box 571770, Murray, UT 84157-1770
8475 E. Hartford Dr., Scottsdale, AZ 85255 5373 S. Green St., Suite 525, Murray, UT 84123
(480) 991-7889 WATS (800) 848-8860 FAX (480) 948-1394 (801)
290-1144 WATS (800) 594-8900 FAX (801) 290-1160
1. Name of the Applicant: _________________________________________ # of owners? ___________
(Complete one questionnaire for each named insured/for each risk)
# of Employees? ________
2. Applicant(s) will operate in the following states: _________________________________________
3. A. Are you a: (Mark all that apply)
Developer General Contractor
Construction Manager Construction Consultant
Subcontractor
B. Number of years of experience you have in this type of work:
C. Have you acted in the capacity of a General Contractor in the past,
or ever held a General Contractors license? Yes No
D. License Number
4. Describe your area of specialization: _________________________________________________
_______________________________________________________________________________
5. Are You a: (Select Yes or No)
A. Residential Remodeling Contractor? Yes No
B. Commercial Tenants Improvements and Betterments Contractor? Yes No
C. Fire / Water Damage Restoration Contractor? Yes No
6. If you answered YES to any of Number 5, then:
A. Do you do additions to building? Yes No
If YES to 6A, please provide details: ___________________________________________
_________________________________________________________________________
B. Is your work interior work only? Yes No
7. List all ACTIVE OWNERS, PARTNERS, OFFICERS and their JOB RESPONSIBILITIES
Individuals Responsibilities
____________________________________ ___________________________________
____________________________________ ___________________________________
____________________________________ ___________________________________
Are any of the above employed supervisors or foremen (who are strictly supervisors)?
Yes No
Are any of the above qualified by education or are any licensed as an Architect, Engineer,
Surveyor or Real Estate Agent or Broker? Yes No
If YES, please explain: ______________________________________________________________
________________________________________________________________________________
ARTISAN CONTRACTORS SUPPLEMENTAL QUESTIONAIRE
Complete in addition to the ACORD Application
Page 1 of 3
8. A. Number of Employees:
B. Employee Payroll (excluding owners/partners/officers): $
9. Have you or are you planning to work on any of the following construction projects?
NEW
REMODEL
A. Apartments
B. Condominiums
C. Townhomes
D. Tract Houses
E. Spec Homes
F. Custom Homes
G. Airport Hangars
H. Industrial Building
I. Mercantile Buildings
J. Commercial
K. Parking Structures
10. For the Classifications below, enter either your employee payroll or the amount of
subcontracted costs including materials. Include for all class codes that apply.
Class
Sub Cost Payroll
Air Conditioning Installation, Service or Repair
Alarm System Install, Service or Repair
Caisson or Cofferdam Work
Carpentry-residential less than 3 stories
Carpentry-Interior
Carpentry-Other
Chimney Cleaning
Concrete Construction-Flat Work
Concrete Construction-Other than Flat Work
Debris Removal
Drywall or Wallboard Installation
Electrical Work-within buildings
Electrical Work-other
Excavation
Fence Erection
Fireproofing
Floor Covering Installation-not ceramic, tile or wood
Floor Covering Installation-other
Grading of Land
Heating, Vacuum or Air Conditioning Install, Service or Repair
Insulation Installation
Janitorial Work
Landscaping
Masonry Work
Painting-Exterior
Painting-Interior
Plumbing-Residential
Plumbing-Commercial
(continued on next page)
Page 2 of 3
Class Sub Cost Payroll
Roofing-Residential (Complete Roofing Supplement)
Roofing-Commercial (Complete Roofing Supplement)
Sewer Main Construction
Siding Installation
Street or Road Construction
Street or Road Paving or Repaving
Swimming Pool Installation, Service or Repair-below ground
Tree Trimming or Pruning
Water Main Construction
Waterproofing
Window Cleaning
Wrecking of Buildings or Structures
Other:____________________________________________
Total
11. Show Gross Sales Figures for the prior 4 years and indicate what the Gross Sales will be
in the upcoming 12 months.
4th Prior Year $_________________
3rd Prior Year $_________________
2nd Prior Year $_________________
Last Year $_________________
This Year $_________________
12. Do you use any of the following: (Mark all that apply)
Casual Labor? Cranes?
Leased Employees? Rented Equipment?
Subcontractors? Explosives?
If YES to any of Question 12, please explain._________________________________________
______________________________________________________________________________
13. Do you carry Workers Compensation Insurance for your employees? Yes No
14. If you use subcontractors, do you require them to provide you certificates of insurance naming
you additional insured? Yes No
What limits of insurance do you require your subcontractors to carry? _____________________
15. Do you have knowledge of any occurrence that might give rise to a claim? Yes No
If YES, please explain: __________________________________________________________
______________________________________________________________________________
16. How many fire extinguisers do you keep at your work premises? ________________
The Applicant represents that the above statements and facts are true and that no material facts
have been suppressed or misstated.
Completion of this form does not bind coverage or commit the company to policy issuance.
Any person who, with the intent to defraud or knowing that he/she is facilitating a fraud against an
insurer, submits an application or files a claim containing a false or deceptive statement is guilty
of insurance fraud.
____________________________________ ___________________________
Applicant Signature Date
Agent's Email Address__________________Preferred Method of Correspondence? Email Fax Regular Mail
Applicant's Email Address_______________Preferred Method of Correspondence? Email Fax Regular Mail
Page 3 of 3
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ARTISAN CONTRACTORS SUPPLEMENTAL QUESTIONAIRE (Colonial General Insurance Agency, Inc)

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Completed 22 August 2020

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