Full Name
Street Address
City
State
Zip Code
Website address. If none, state NONE.
Email address. If none, state NONE.
Years in business under present name:
Tax ID#
Years of experience in this field:
CONTRACTING OPERATIONS (select all that apply) General Contractor Developer Owner/Builder Subcontractor Construction Manager Consultant
Please provide % of fees attibutable to each operations stated above. (example: General Contractor 100%)
Have you operated under any other names? Yes No
If yes, please explain.
Present or prior affiliation with any other firms? Yes No
Employee Count: Full Time: Part Time:
Contractor License Number:
What year was the license issued?
Who is your present insurer? If you do not have coverage currently, state NONE.
If currently insured, what are your limits of liability? If none, state NONE.
If currently insured, what is your deductible or SIR? If none, state NONE.
If you have a claims made policy, what is your retroactive date? If none, state NONE.
Has any insurer ever cancelled, restricted or refused to renew your General Liability policy? Yes No
Please list all States in which you operate.
Please provide a list of your 5 largest jobs, include date job completed, type of work performed and job cost:
Provide the gross sales, payroll and subcontract costs projected for this year: GS: $ P:$ SUB:$
Provide the gross sales, payroll and subcontracted costs for the most recent 12 months: GS: $ P:$ SUB:$
Provide the gross sales, payroll and suncontracted costs for the 12 month period that ended 24 months ago: GS: $ P:$ SUB:$
Provide the gross sales, payroll and subcontracted costs for the 12 month period that ended 36 months ago: GS: $ P:$ SUB:$
Provide the gross sales, payroll and subcontracted costs for the 12 month period that ended 48 months ago: GS: $ P:$ SUB:$
Provide the gross sales, payroll and subcontracted costs for the 12 month period that ended 60 months ago: GS: $ P:$ SUB:$
Types of construction operations: New Construction Commercial Remodeling Residential Repair Industrial Demolition Instiutional Other
Provide % for each of the above selected operations. (Total to equal 100%)
Indicate employee payroll and subcontractor costs for each type of work performed: (example: Electrical: EP:$25,000 SUB:$5,000)
Any past, present or future work on hillsides, hilltops or terraces? Yes No
Any past, present or future work on landfill areas or in subsidence areas? Yes No
Any past, present or future construction operations conducted in excess of 2 stories? Yes No
Any past, present or future exterior work performed above 2 stories in height from grade? Yes No
If yes, what is the maximum # of stories and percentage of total work?
Any past, present or future work performed below grade? Yes No
If yes, what is the maximum depth and percentage of total work?
Any past, present or future involvement in the construction of condos, townhouses or apartments? Yes No
If yes, please explain:
Any past, present or future involvement with EIFS or Synthetic Stucco? Yes No
Any past, present or future involvement in the building of Tract Housing Developments? (Tract defined as 6 or more homes in the same subdivision) Yes No
Average # of homes built projects completed annually:
Average cost of job?
Have you worked or will you or your employees work under USL&H or Jones Act? Yes No
Do you have a formal safety program in operation? Yes No
Please explain, we will need a copy prior to binding.
Do you use subcontractors? Yes No
What is the percentage of subcontracted work?
What are the annual subcontracting costs? (including all subs’ labor and materials)
Are certificates of insurance obtained from subcontractors? Yes No
What are the minimum limits you require from the subcontractors?
Are written contracts obtained from all subcontractors which include a hold harmless clause in your favor? Yes No
If no, explain when not required:
Do you draw any plans or blueprints used in your construction work? Yes No
If yes, has Professional Liability Coverage been obtained? Yes No
What is the Professional Liability limit purchased?
Do you own any vacant land held only for investment of possible development more than 12 months future? Yes No
If yes, is the property zoned as residential or non-residential?
Do you own any real estate development property (land with improvements-streets, roads or utilites, etc….completed under construction? Yes No
Total # of acres of vacant land?
Total # of acres of Real Estate Dev Prop:
Do you have any other operations other than mentioned here? If yes, explain below:
Have you had any claims the last 5 years? Yes No
If yes, the currently valued hard copy loss runs will be required prior to binding. Please provide a loss summary below. For each of the preceeding 5 years, please provide the # of Claims, # of Claims Still Open,Total Paid, and Total Reserved.
Any subsidence or sinkhole related losses in the past 5 years? Yes No
Have you ever been named in a construction defect suit? Yes No
If yes, provide detials:
Are you aware of any other incidents which may result in claims against you?
If yes, please give details:
Would you like a quick quote for Employment Practices Liability? Yes No
Please utilize the “Send” Button to send your form to our office. If the website does not allow you to submit the form, please print the page and fax it to 732.334.0405 or scan it into your computer and send it to ben@zolofrainsurance.com. Do not “Refresh” the page because all data entered onto the form will be lost.
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