1.	Applicant Name

2.	Address

Current Carrier:	Current Premium:
3.	Years in business	Website:
4.	Has the applicant operated under any other name in the past 5 years?	Yes □	No □
5.	States in which the applicant operates:

6.	Has the applicant operated in any other states during the past 5 years?	Yes □	No □
7.	Gross Receipts for next 12 months	$
Gross Receipts for past 12 months	$
Gross Receipts for second prior year	$
8.	List and describe the applicant’s five largest projects during the last 5 years:
Project Name	Description	Construction Values
9.	Has or will the applicant perform any of the following:
Work under a “Wrap Up” or “OCIP” or similar plan?	Yes □	No □
Work on bridges, dams or tunnels?	Yes □	No □
Work through a joint venture agreement?	Yes □	No □
10	List Percentage of work as:
General Contractor	%	Prime Contractor	%	Subcontractor	%
11	Projected Payrolls by classes for upcoming year:
Blasting	$	Grading	$	Residential Roofing	$
Bridges
Heating/AC
Commercial Roofing
Carpentry
Insulation
Sewer
Concrete
Landscape
Steel Structural
Const Mgmt
Masonry
Steel Ornamental
Electrician
Mechanical
Street & Road
Excavation
Millwright
Stucco
EIFS
Painting
Supervision
Debris Removal
Permanent Yard
Water/Gas Main
Demolition
Plastering
Welding
Drilling
Plumbing
Other
12.	Total Projected Subcontractor Costs
Major Classes Subcontracted to others, please check the classes that represent subcontracted work:
Blasting □	Bridgework □	Carpentry □	Concrete □	Electrical □	Excavation □
Debris Removal □	Demolition □	Drilling □	Grading □	Insulation □	Landscape □
Plastering □	Plumbing □	Roofing □	Sewer □	Steel □	Water/Gas □
13.	Does the applicant require all Subcontractors to sign a standard written agreement? Please attach a copy of that agreement.	Yes □	No □
Is the subcontractor allowed to begin work without having signed the agreement?	Yes □	No □
Does that agreement require the Subcontractor to:
Carry Commercial General Liability Insurance?	Yes □	No □
At limits less than those being applied for hereon?	Yes □	No □
Add the applicant as an Additional Insured?	Yes □	No □
Does the agreement specify the type of Additional Insured endorsement required?	Yes □	No □
Waive its right of subrogation against the applicant?	Yes □	No □
Does the applicant receive Certificates of Insurance from all Subs?	Yes □	No □
Has the applicant always done so?	Yes □	No □
How long does the applicant keep copies of certificates on file?
What is the applicant’s procedure for tracking Certificates of Insurance:

What is the applicant’s procedure for ensuring that the subcontractor has added the insured as an Additional Insured?

14.	Has the applicant built on hillsides, slopes, landfills or subsidence areas?	Yes □	No □
Will the applicant work on such projects in the current year?	Yes □	No □
If yes, please provide details including maximum degree of slope:
15.	Has the applicant constructed any buildings or structures in excess of two stories during the past five years?	Yes □	No □
16.	What is the maximum exterior height at which the applicant will work? Feet
17.	Does the applicant use cranes or booms?	Yes □	No □
Does applicant own the crane or boom equipment?	Yes □	No □
Is any crane or boom equipment rented or leased without operator?	Yes □	No □
Is any crane or boom equipment rented or leased with operator?	Yes □	No □
If the answer to the preceding question is yes, does the applicant obtain an indemnification agreement from the equipment leasing or rental firm?	Yes □	No □
Does the applicant obtain Additional Insured coverage from the equipment leasing or rental firm?	Yes □	No □
Does the applicant lease or provide crane or boom equipment to others?	Yes □	No □
Is there an equipment maintenance program for owned cranes or booms?	Yes □	No □
Are Load Charts posted in the cab of any crane or boom?	Yes □	No □
Do Load Charts show limits based on boom angle and height of load above ground?	Yes □	No □
Are boom angle indicators posted in the cab?	Yes □	No □
What is the length and number of booms or cranes?	Length in feet:	Unit count:
If this equipment is operated by an employee of the applicant, describe the experience level of the operator:
Has the applicant experienced any claim, incident or circumstance regarding cranes or booms in the past 5 years?	Yes □	No □
18.	Does Applicant use scaffolding?	Yes □	No □
Is the scaffolding equipment used owned by the applicant?	Yes □	No □
If rented from others does applicant do so under a rental contract?	Yes □	No □
19.	Do any of the applicant’s current, past or future planned projects involve caissons, cantilevers, piers, retaining walls, shoring, underpinning, or other heavy structural engineering techniques?	Yes □	No □
20.	Does the applicant perform work below ground level?	Yes □	No □
21.	List the maximum depth at which the applicant works, in feet	Feet
22.	Has the applicant been involved in the construction of, or work on single-family dwellings, condominiums, townhouses or apartments?	Yes □	No □
Will the applicant work on such projects in the current year?	Yes □	No □
Has the applicant ever done any work for a residential developer?	Yes □	No □
Has the applicant ever done any work for residential general contractors?	Yes □	No □
23.	Has the applicant worked on the building, removal, repair or replacement of roofs?	Yes □	No □
Will the applicant work on such projects in the current year?	Yes □	No □
24.	During the past five years has any insurance company canceled, declined or refused to issue, or refused to renew similar coverage to the applicant?	Yes □	No □
25.	Enter all claims or occurrences for the past five years, or	Check here if none
Check here if current Loss Runs are attached
Description	Date of Claim	Amount Paid	Amount Reserved	Status
25. Has any lawsuit ever been filed, or any claim otherwise been made against the applicant or any partnership or joint venture of which the applicant has been a member or the applicant’s predecessors in business, or against any person, company or entities on whose behalf the applicant has assumed liability? Yes □ No □
26. Has the applicant been involved in a claim for construction defects? Yes □ No □
27. Is the applicant aware of any incident, circumstance, defect or alleged defect including but not limited to: faulty or defective workmanship, product failure, construction dispute, product failure, property damage or subcontractor or construction worker injury, that a reasonably prudent person might expect to give rise to a claim or lawsuit, whether valid or not, which might involve the applicant?

Yes □ No □
Information contained herein is specifically relied upon in determination of insurability. The undersigned therefore warrants that the information contained herein is true and accurate to the best of his knowledge, information and belief. This Contractors Supplemental Questionnaire, and the application to which it is attached shall be the basis of any insurance policy that may be issue and will be a part of such policy

Signature of applicant:	Date

Printed Name and Title:

Contractor’s Supplemental Questionnaire

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Francis P McGovern

2003-05-27

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