Front Range Insurance & Financial Services, LLC - IPM Colorado Contractors Questionnaire Form

1. Applicant Name:*

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 active, inactive or dissolved?*

YesNo

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?*

YesNo

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:

A. New York State Applicants: Any work in the five boroughs of New York?*

YesNo

B. All Applicants: Do you do any work in Colorado?*

YesNo

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?*

YesNo

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
Percentage (%):

6. Do you use Subcontractors?*

YesNo

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?*

YesNo

If yes, please explain:

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

YesNo

9. Do you collect certificates of insurance from all subcontractors?*

YesNo

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?*

YesNo

C. Do you require all subcontractors to defend, indemnify and hold you harmless from their activities and is this part of the written contract?*

YesNo

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: $
Estimate:

5 Years Prior History if Applicable:*

	1st Year Gross Receipts:	2nd Year Gross Receipts:	3rd Year Gross Receipts:	4th Year Gross Receipts:	5th Year Gross Receipts:
$

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

	New Construction	Remodeling/Repair	Other
RESIDENTIAL

	New Construction	Remodeling/Repair
COMMERCIAL

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:*

	% Direct	% Subbed
Airport Runways
Blasting
Bridge Building
Carpentry
Concrete
Demolition
Door / Window
Drilling
Drywall
Earthquake
Electrical
Excavation
Fire Sprinkler
Grading
HVAC
Insulation
Maintenance
Masonry
Mechanical
Painting
Plastering
Plumbing
Roofing
Seismic/Retrofitting
Sewer
Shower Door
Steel/Structural
Steel/Ornamental
Street/Road
Supervisory Only
Traffic Signals
Water/Gas Mains
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:

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?*

YesNo

A. How long ago?

B. How many?

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

A. Ongoing Operations only*

YesNo

B. Ongoing Operations including Completed Operations*

YesNo

C. If yes, do you wish coverage for this exposure*

YesNo

18. Do you anticipate needing Waivers of Subrogation in the next year?*

YesNo

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?*

YesNo

A. Has any other licensing authority taken any action against you?*

YesNo

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

YesNo

If yes, please explain:

Our policy is not intended to provide coverage for this exposure. Do you wish coverage:*

YesNo

21. Do you use scaffolding?*

YesNo

If yes, please explain:

22. Have you been involved or will you be involved with blasting operations or any other hazardous work activity?*

YesNo

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)?*

YesNo

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

YesNo

24. Do any of your subcontractors perform EIFS work?*

YesNo

Do you verify that coverage for this exposure is in place and not excluded?*

YesNo

25. Have you built/demolished or will you build/demolish buildings or other structures in excess of four (4) stories?*

YesNo

If yes, please explain:

26. Do you perform work above two stories in height? (other than interior remodel)*

YesNo

If yes, what percentage?

Maximum Height?

Please describe:

27. Do you perform any work at Airports?*

YesNo

If yes, please explain:

28. Do you own, rent or subcontract any cranes?*

YesNo

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?*

YesNo

30. Removal or work on fuel tanks or pipelines?*

YesNo

31. If you are a roofing contractor, subcontractor or performing roofing work, do you use (please also answer if you hire subcontractors to complete this work):

32. Do you perform any Mold Remediation Work?*

YesNo

33. Do any of your subcontractors perform Mold Remediation Work?*

YesNo

A. If yes, is coverage in place?

YesNo

B. Name of Carrier?

34. Have you performed or will you or your subcontractors perform any work below grade:*

YesNo

Maximum Depth (in inches):

% of operations:

35. Any shoring, underpinning, cofferdam or caisson work?*

YesNo

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?*

YesNo

37. Do you have a formal safety program in place?*

YesNo

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

YesNo

A. If yes, is the work new construction?

YesNo

B. Repair or Remodel only?

YesNo

C. Is the work done for Homeowners Associations (not individual unit owners?)

YesNo

39. Have you ever worked in new condominiums/townhouses?*

YesNo

If yes, how long ago?

40. Will your upcoming work involve the construction of or involvement with apartments?*

YesNo

A. If yes, is the work new construction?

YesNo

How many units in the entire Project?

B. Repair or Remodel only?

YesNo

41. Have you ever worked in new Apartments?*

YesNo

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?*

YesNo

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

Are the units individually owned and titled?

YesNo

43. Have you ever worked in new Duplexes, Triplexes, Fourplexes or Patio Homes?*

YesNo

If yes, how long ago?

Maximum number in any development?

44. Will your upcoming work involve construction in any new home tracts?*

YesNo

If yes, maximum number of homes in ENTIRE TRACT DEVELOPMENT

45. Have you ever worked in new tract developments?*

YesNo

If yes, how long ago?

How many units in the entire development?

46. Any current Wrap-Up/OCIP/CCIP Projects?*

YesNo

A. Name of Carrier?

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

YesNo

If yes, how long ago?

How many units in the entire building?

Does it involve any individual unit ownership?*

YesNo

48. Have you or will you ever convert apartments to condominiums?*

YesNo

49. Any other exposures/operations not otherwise covered by this questionnaire?*

YesNo

If yes, please explain:

50. Have there been any losses, claims or suits against you in the past eight years?*

YesNo

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? *

YesNo

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?*

YesNo

If yes, please describe:

c. Have you been accused of faulty construction in the past 8 years?*

YesNo

If yes, please describe:

d. Have you been accused of breaching a contract in the past 8 years?*

YesNo

If yes, please describe:

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

Front Range Insurance - Stucco Contractors Questionnaire

DEFINITIONS: