Fill - Colorado Contractors Supplemental

Page 1 of 7 CO_VCQ 0

COL

ORADO CONTRACTORS

QUESTIONNAIRE

ALL QUESTIONS MUST BE ANSWERED (Attach additional paper if necessary)

1. Applicant: _________________________________________________________________________

A. Years in business under current name: _________

B. Describe your operations: __________________________________________________________

C. Do you currently have, or have you had in the past, a controlling interest in any other similar operations whether

act

ive, inactive or dissolved? Yes No

If yes, please describe: _________________________________________________________

D. 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:

______________________________________________________________________________

2. 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

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

_________________________________________________________________________________

A. Describe the operations: __________________________________________________________

4. 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: ______________________________________________________________

5. Percentage of current operations: General Contractor ____% Subcontractor ____% Construction Mgr: ____%

6. Do you use Subcontractors? Yes No If yes, please complete the following:

A. Percentage of subcontracted work: ____________%

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

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

yourself: __________________________________________________________________________

__________________________________________________________________________________

D. Are there any circumstances when you do work for a general contractor that you use a subcontractor? If yes,

please describe:_____________________________________________________________________

__________________________________________________________________________________

7. Any prior GL policies written on a claims-made basis? If yes, please explain: Yes No

__________________________________________________________________________________

8. Have any of your prior policies contained a Prior Acts Exclusion?

Yes No

Page 2 of 7 CO_VCQ 

9. Do you collect certificates of insurance from all su

bcontractors? Yes No

A. What limits of coverage are required from these subcontractors? $_______________________

B. 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

C. 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

D. Who reviews and maintains the certificates? _____________________________________________

E. How long are they kept? __________________

10

. Estimates for next 12 months:

Payroll $______________ Sub-Contract Cost $______________ Gross Receipts: $________________

5 Years Prior History if Applicable: 1

st

Year Gross Receipts: $________________

2

nd

Year Gross Receipts: $________________

3

rd

Year Gross Receipts: $________________

4

th

Year Gross Receipts: $________________

5

th

Year Gross Receipts: $________________

11. Indicate the percentage of construction work preformed by you: (MUST TOTAL 100%)

RESIDENTIAL _______% COMMERCIAL _______%

New Construction _______% New Construction _______%

Remodeling/Repair _______% Remodeling/Repair _______%

Other _______________________ _______%

12. Using percentage of payroll (under Direct) and percentage of contract costs (under Subbed), indicate the

anticipated percentage of construction work you will perform over the next 12 months:

Type of Work %

Direct

%

Sub

bed

Type of Work %

Direct

%

Subbed

Type of Work %

Direct

%

Subbed

Airport Runways Excavation Roofing

Blasting Fire Sprinkler Seismic/Retrofitting

Bridge Building Grading Sewer

Carpentry HVAC Shower Door

Concrete Insulation Steel/Structural

Demolition Maintenance Steel/Ornamental

Door/ Window Masonry Street/Road

Drilling Mechanical Supervisory Only

Drywall Painting Traffic Signals

Earthquake Plastering Water/Gas Mains

Electrical Plumbing Other:

13. Describe your four largest projects over the past five years, including values:

________________________________________________________________________________________

14. List current projects currently underway or planned for the next year, including values:

________________________________________________________________________________________

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15. How many new homes will you build from the ground up in the next year? _________

16

. Have you ever built a home from the ground up? Yes No

A. How long ago? ______________ B. How many? ________________________

17. What type of Additional Insured Endorsements are you required to produce?

A. Ongoing Operations only Yes No

B. Ongoing Operations including Completed Operations Yes No

C. If yes, do you wish coverage for this exposure____________________________________ Yes No

18. Do you anticipate needing Waivers of Subrogation in the next year? Yes No

19. 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

A. Has any other licensing authority taken any action against you? Yes No

20. Have you built or will you build on hillsides, terraces, landfills or areas with recent

subsidence activity? Yes No

If yes, please explain: __________________________________________________________

Our policy is not intended to provide coverage for this exposure. Do you wish coverage: Yes No

21. Do you use scaffolding? Yes No

If yes, please explain: __________________________________________________________

22. Have you been involved or will you be involved with blasting operations or any other

hazardous work activity? Yes No

If yes, please explain, include if work is done by sub-contractors of if done by you:

____________________________________________________________________________

23. Do you perform synthetic stucco work (EIFS)? Yes No

Are you interested in coverage for EIFS work? If so, please complete the separate application.

Yes No

24. Do any of your subcontractors perform EIFS work? Yes No

Do you verify that coverage for this exposure is in place and not excluded? Yes No

25. Have you built/demolished or will you build/demolish buildings or other structures in excess

of four (4) stories? Yes No

If yes, please explain: __________________________________________________________

26. Do you perform work above two stories in height? (other than interior remodel) Yes No

If yes, what percentage? __________% Maximum Height? __________

Please describe: _______________________________________________________________

27. Do you perform any work at Airports? Yes No

If yes, please explain: ___________________________________________________________

28. Do you own, rent or subcontract any cranes? Yes No

If yes, please explain: ___________________________________________________________

29. 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

30. Removal or work on fuel tanks or pipelines? Yes No

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31. If you are a roofing contractor, subcontractor or performing roofing work, do you use (please also answer if

yo

u hire subcontractors to complete this work):

Hot Tar ______% Yes No

Torch Down Yes No

Modified Bitumen (HOT) Yes No

Modified Bitumen (COLD) Yes No

Hot Air Welding ______% Yes No

Other: ___________________________________

32. Do you perform any Mold Remediation Work?

Yes No

33. Do any of your subcontractors perform Mold Remediation Work? Yes No

A. If yes, is coverage in place? Yes No

B. Name of Carrier? _________________________________________

34. Have you performed or will you or your subcontractors perform

any work below grade: Yes No

Maximum Depth: _________ inches % of operations: ________

35. Any shoring, underpinning, cofferdam or caisson work? Yes No

If yes, please explain: _____________________________________________________________

36. 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

37. Do you have a formal safety program in place? Yes No

38. Will your upcoming work involve construction of or involvement with condominiums or townhouses?

Yes No

A. If yes, is the work new construction? Yes No

B. Repair or Remodel only? Yes No

C. Is the work done for Homeowners Associations (not individual unit owners?) Yes No

39. Have you ever worked in new condominiums/townhouses? Yes No

If yes, how long ago? _______________

40. Will your upcoming work involve the construction of or involvement with apartments? Yes No

A. If yes, is the work new construction? Yes No

How many units in the entire Project? ___________

B. Repair or Remodel only? Yes No

41. Have you ever worked in new Apartments? Yes No

If yes, how long ago? _______________ How many units in the entire building? __________

42. Will your upcoming work involve the construction of or involvement with new Duplexes,

Triplexes, Fourplexes or Patio Homes? Yes No

If Yes, what is the maximum number in any development? _________

Are the units individually owned and titled?

Yes No

43. Have you ever worked in new Duplexes, Triplexes, Fourplexes or Patio Homes? Yes No

If yes, how long ago? _______________ Maximum number in any development? _________

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44

. Will your upcoming work involve construction in any new home tracts? Yes No

If yes, maximum number of homes in ENTIRE TRACT DEVELOPMENT ________

45. Have you ever worked in new tract developments? Yes No

If yes, how long ago? _______________

How many units in the entire development? _______________

46. Any current Wrap-Up/OCIP/CCIP Projects? Yes No

A. Name of Carrier? _______________________________________

47. Have you ever worked in new assisted living facilities?

Yes No

If yes, how long ago? ______________ How many units in the entire building? __________

Does it involve any individual unit ownership? Yes No

48. Have you or will you ever convert apartments to condominiums? Yes No

49. Any other exposures/operations not otherwise covered by this questionnaire? Yes No

If yes, please explain: __________________________________________________________

50. Have there been any losses, claims or suits against you in the past eight years? Yes No

If yes, please describe: _________________________________________________________

a. Are there any claims or legal actions pending against any active, inactive or dissolved entities

in which you have had a controlling interest? Yes No

If yes, please describe: _________________________________________________________

b. After inquiry, do you have knowledge of any pre-existing act, omission, event, condition or damage to any

person or property that might reasonably be expected to give rise to any future claim or legal action against any

person or entity identified in the application?

Yes No

If yes, please describe: _________________________________________________________

c. Have you been accused of faulty construction in the past 8 years? Yes No

If yes, please describe: _________________________________________________________

d. Have you been accused of breaching a contract in the past 8 years? Yes No

If yes, please describe: _________________________________________________________

Page 6 of  CO_VCQ 0

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.

Signature of Applicant:* ____________________________________________________________

Name & Title: ___________________________________________________Date: ____________

*Must be owner, executive officer or partner of the company

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Page 7 of 7 CO_VCQ 03 14

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