Janitorial Insurance Questionnaire

Applicant's Name:

Address:

Mailing Address

Address (cont):

Mailing Address - continued

Contact:

Email

Telephone:

Website

Fax:

Applicant is:

Current Carrier:

Expiration Date:

Limits: ($)

Premium: ($)

Deductible: ($)

How did you hear about us?

Other

GENERAL INFORMATION

1. Year business started?

2. How many years under current management?

3. Have you operated this business under any other name?

3a. If yes, provide business name:

4. Number of employees

5. Breakdown of Work

Rows	Percentage
1 or 2 Family Dwellings
Apartments
Commercial
Industrial
Municipal
Medical

6. List the states in which you work in or plan to work in:

7. What is the maximum number of projects at any one time?

8. What is your radius of operations?

9. Do you offer design or Engineering Services?

9a. If yes, please describe:

10. Do you act as Property Manager?

11. Do you subcontract work to others?

11a. If yes, what is the percentage of work subcontracted work and describe what is being subcontracted?

12. Do you have a written subcontractor agreement? If yes, please attach agreement.

If yes to question 12, please complete the following:

Rows	Yes	No	Type answer for 12di here
12a. Do the contracts contain hold harmless and indemnification provisions in your favor?
12b. Do the contracts require you to be added to the sub’s policy as an additional insured on a Primary and Noncontributory basis, for all liability and expenses arising out of their work, including completed operations?
12c. Do the contracts require the subs carry limits equal to or greater than $1,000,000 for General Liability and Motor Vehicle Liability?
12d. Do you require the subcontractor to carry an Umbrella?
12di. If yes to umbrella requirement for subcontractor, what limit do you require?
12e. Do you validate that the subcontractor has Workers Compensation Insurance?
12f. Do you require the subcontractor to provide a waiver of subrogation on your behalf under General Liability, Motor Vehicle Liability, and Workers Compensation?
12g. Do you require certificates of insurance from all your sub-contractors prior to their starting on a project?
12h.Do you require the subcontractor be in compliance with the insurance requirements of the contract before they are paid in full?

13. Do you use an unmanned aircraft vehicle?

3. Check all that apply to your operation:

14. Do you snowplow for others?

14a. if yes, breakdown of snowplowing customers:

Rows	Percentage
Residential
Commercial
Municipal

14a. List the insured’s major customer:

14b. Any plowing on public streets, roads or highways?

14c. Does the insured perform any salting or sanding operations?

14d. Total receipts from snowplowing operations:

14e. Does the insured clear:

Rows	Any thoughts?
On the insured’s own timetable
Only upon customer’s request or call
As written in contract (attached)

14f. Does insured keep a log of jobs completed?

SNOWPLOWING FOR COMMERCIAL CUSTOMERS REQUIRES WRITTEN CONTRACTS. WRITTEN CONTRACTS MUST BE SUMBITTED FOR REVIEW BEFORE WE CAN DETERMINE UNDERWRITING ACCEPTABILITY.

Encourage snow clearance contractors to consult with their attorneys regarding how to limit their loss exposures and manage their risks of liability.

15. Do you have an equipment maintenance program in place?

16. Is all equipment secured at the jobsite when not in use?

17. Is all equipment secured at the jobsite when not in use?

17a. If yes, please explain:

18. Does the insured lease, rent, or borrow equipment from others?

18a. If yes, how much is spent annually to rent equipment?

19. Do you have a formal fleet safety program in place?

20. Do you run Motor Vehicle Records (MVR) on all employees that you furnish a company vehicle to?

20a. If so, do you have a driver eligibility program in place that differentiates what is considered anacceptable MVR?

21. Do you have a formal fleet maintenance program in place?

Rows	Percentage
1. Janitorial (basic cleaning):
2. Carpet or Upholstery Cleaning:
3. Specialty Rug Cleaning (oriental, etc.)
4. Apply Floor Wax
5. Strip Floor Wax - If performed, see below.
6. Outside Maintenance Work - if performed, see below
7. Window Cleaning - if perfomred, see below
8. Medical Office Work
9. Water / Fire Restoration

Rows	Building Age	Building Construction	Building Limit ($)	Content Limit ($)
Building 1
Building 2

Rows	Year	Make	Model	Value to Insure For ($)
Item 1
Item 2
Item 3

Rows	Vehicle Make	Vehicle Model	Cost New ($)	Year
Vehicle 1
Vehicle 2
Vehicle 3

Rows	Amount ($)
Limit of Liability
Comprehensive Deductible
Collision Deductible