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- Contractors App 2012 (Access E&S Insurance Services)

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GSL 7717XXc ed 01-2012
Page 2 of 5
OPERATIONS AND ACCOUNTING YEAR INFORMATION
4. A. Is your company a General Contractor? Y N Is your company a Specialty Contractor? Y N
** If your company is performing Design Only, Agency Construction Management or General Contracting
services, your company will be considered on our Contractors Professional Liability Policy form. If your
company is performing Specialty Contracting services, your company will be considered under our Contractors
Errors & Omissions Policy form.
B. If your company is a Specialty Contractor, are there separate projects where your company would perform services
as a General Contractor?
Y N If yes, please provide an explanation in the space provided.
5. Report all construction revenue generated by every entity to be listed as a Named Insured broken down by the
following contract types/activities:
Reporting Periods
Past 12 Months Estimate For Next 12 Months
From: /
To: / From: / To: /
Types of
Contracts/Activities
Construction
Revenue Professional Fees
Estimated
Construction Revenue Professional Fees
A. Design Only
$ $ $ $
B. Construction Only
$
$
C. Agency CM
$ $ $ $
D. At-Risk CM
$ $ $ $
E. Design-Build w/In-
House Design
$ $ $ $
F. Design-Build
w/Subcontracted Design
$ $ $ $
G. Other
$ $ $ $
TOTALS:
$ $ $ $
6. A. Do you require professional liability or errors & omissions coverage of your sub-consultants? Y N
B. If yes, what are the minimum limits required? per claim per aggregate.
PROJECTS
7. Please provide a breakdown of your company’s project types into the following categories.*
Airport Facilities (except
terminals)
%
Hospitals/Health Care
%
Petro/Chemical
%
Airport Terminals
%
Hotels/Motels
%
Potable/Storm Water Systems
%
Amusement Rides
%
Single Family Residential
%
Recreation/Sports
%
Apartments/Multi-family
%
Jails/Justice
%
Roads/Highways
%
Assisted Living Facilities
%
Landfills/Solid Waste Facilities
%
Schools/Colleges
%
Bridges/Dams/Tunnels
%
Libraries
%
Shopping Centers/Retail/
Restaurants
%
Churches/Religious
%
Manufacturing/Industrial
%
Warehouses
%
Condos/Co-ops
%
Mass Transit
%
Water/Sewer Pipelines
%
Convention
Centers/Arenas/Stadiums
%
Nuclear/Atomic
%
Water/Wastewater Treatment
%
Dormitories
%
Office Buildings/Banks
%
Utilities (Gas, Electric, Steam)
%
Environmental Remediation
%
Parking Structures
%
Other (specify)
%
Harbors/Piers/Ports
%
Parks/Playgrounds/ Pools
%
Other (specify)
%
*Total should equal 100%
8. Please provide total construction revenue for each of the past 3 years.
GSL 7717XXc ed 01-2012
Page 3 of 5
Total Construction Revenue Year
$
$
$
RISK MANAGEMENT AND LOSS PREVENTION
9. Does your company have a written in-house quality management procedure? Y N
10. A. What percentage of your company’s projects use a written contract?
%
B. What percentage of your company’s professional services are rendered under AGC, AIA, CMAA,
Consensus Documents, DBIA or EJCDC documents?
%
11. What percentage of of your company’s professional employees have participated in continuing
education in the past 12 months?
%
BUSINESS INFORMATION
If the response is “yes” to any question in this section, please provide details in the space provided after question
26 of the application.
12. A. Does your company or any principal, partner, officer, director or shareholder or an immediate family
member of any such person have more than a 49% combined ownership interest or act as the managing
partner in any entity or project for which professional services have been or are to be rendered?
Y N
B. Does your company render services on behalf of any other entity in which any principal, partner,
officer, director or shareholder or an immediate family member of such person is a partner, officer,
director, shareholder or employee?
Y N
C. Is your company controlled, owned by, or does your company control or own, any other entity not
listed on this application?
Y N
13. Is your company engaged in real estate development?
Y N
14. A. Has your company ever held or do you now hold a patent for any product or process? Y N
B. Is your company engaged in the manufacture, sale or distribution of any product? Y N
15. Has your company or any predecessor ever declared bankruptcy? Y N
16. Please provide the following information for your current policies: (Applicants must carry General Liability and Umbrella
Liability Limits equal to or greater than the Professional Liability or Errors/Omission limits being requested.)
Particulars General Liability Umbrella Liability
a. Insurer
b. Policy Limits
c. Policy Deductible
Five year General Liability Loss Ratio: %
Current Workers Compensation Modifier:
Please attach details regarding incurred or paid losses in excess of $100,000 and/or open claims.
CONTRACTOR’S POLLUTION LIABILITY RISK INFORMATION
17. Does your company have written policies and procedures for complying with OSHA health, safety, training
and medical monitoring requirements?
Y N
18. Does your company have a written health and safety manual?
When was it last updated?
Y N
19. Does your company carry Contractor’s Pollution Liability coverage? Y N
If yes, please provide the following information:
A. Name of Insurer:
B. Limit of Liability per claim:
/ aggregate
C. Deductible/SIR/per claim
/ aggregate
D. Retroactive date
E. Annual Premium
20. Is your company ever responsible for removing or transporting waste from job sites. If yes, please include
how often and job types.
Y N
21. Does your company subcontract the disposal and/or transportation of waste?
If yes, do you require the subcontractor to name you as an additional insured on their pollution liability
policy?
Y N
Y N
GSL 7717XXc ed 01-2012
Page 4 of 5
NEW APPLICANT INFORMATION
Professional Liability, Faulty Workmanship, Defective Products Liability and/or Pollution Liability Claim Information
22. Have any claims been made or legal action been brought in the past ten years (or made earlier and still
pending) against your company, its predecessor(s) or any past or present principal, partner, officer,
director, shareholder or employee? If yes, provide the following information for each claim in the space
provided after question 26 of the application.
Y N
A. Date of claim E. Insurance company reserve, if any
B. Claimant or Plaintiff F. Defense attorney’s or insurance company’s evaluation of exposure/potential liability
C. Allegations G. Defense and indemnity paid to date and status (open/closed)
D. Demand or amount of claims H. Deductible applicable
23. After complete investigation and inquiry, do any of the principals, partners, officers, directors, members,
shareholders, employees, or insurance managers have knowledge of any act, error, omission, fact,
incident, situation, unresolved job dispute (including owner-contractor disputes), accident, or any other
circumstance that is or could be the basis for a claim under the proposed insurance policy?
Y N
If yes, please give details of this situation, including name of project and claimant, dates, nature of situation and amount
of damages in the space provided after question 26 of the application.
Report knowledge of all such incidents to your current carrier prior to your current policy expiration.
The policy of insurance being applied for will not respond to incidents about which you had knowledge prior to the
effective date of the policy nor will coverage apply to any claim or circumstance identified or that should have been
identified in Questions 22 and 23 of this application.
24. Has any insurer declined, cancelled or refused to renew any similar insurance for your company or any
predecessor firm? (N/A in Missouri)
Y N
If yes, please give details.
25. Do you or any subsidiary or predecessor company have any current outstanding errors & omissions,
professional liability or pollution liability SIR/deductible obligations? Y N
If yes, please give exact amount owed to insurance company and, if a payment schedule is in place, the amount and
dates of repayments in the space provided after question 26 of the application.
26. Has any similar insurance been issued to any of the company(ies) named in Question 1. If yes, please
complete the following for the last five years. Y N
Company Policy # Limit Deductible/SIR Dates Premium
1.
2.
3.
4.
5.
Retroactive coverage date on current policy (if applicable)
Explanations to questions above: (please specify the corresponding question number with the explanation)
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Completed 8 January 2021

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