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:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Page 3 of 7 CO_VCQ 0
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
Page 4 of 7 CO_VCQ 0
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? _________
Page 5 of 7 CO_VCQ 0
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
click to sign
signature
click to edit
Page 7 of 7 CO_VCQ 03 14
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome