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CONTRACTORS QUESTIONNAIRE FOR VELA INSURANCE SERVICES

By Jay Diaz,2014-05-13 00:05
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CONTRACTORS QUESTIONNAIRE FOR VELA INSURANCE SERVICES

    CONTRACTORS QUESTIONNAIRE VELA INSURANCE SERVICES

    ALL QUESTIONS MUST BE ANSWERED (Attach additional paper if necessary)

1. Applicant: ______________________________________________________________

    A. Years in business under current name: _________

    B. Describe your Operations: _________________________________________________________

    C. Do you have any other operations active or inactive? Yes No

     If yes, please explain: ____________________________________________________________

    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? Yes No

3. List all other business names & licenses active or inactive applicant has used in the past 10 years:

    ____________________________________________________________________________________

     A. What were the operations? ____________________________________________________

4. Does applicant currently own/operate any other business? Yes No

     If yes, need name and percentage of ownership: ____________________________________________

     What are the operations? ______________________________________________________________

5. Percentage of current operations: General Contractor ____% Subcontractor ____% Constr. Mgr: ____%

6. Do you use Subcontractors? Yes No If yes, please complete the following:

     A. Percentage of subcontracted work: ____________%

     B. Annual subcontracting cost (including all of subs’ labor and materials: $____________

7. Do you collect certificates from all subcontractors? Yes No

     A. What limit is required from these subcontractors? $_____________________

    8. Estimates for next 12 months:

    Payroll $______________ Sub-Contract Cost $______________ Gross Receipts: $________________

     st4 Years Prior History if Applicable: 1 Year Gross Receipts: $________________ nd 2 Year Gross Receipts: $________________ rd 3 Year Gross Receipts: $________________ th 4 Year Gross Receipts: $________________

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

     RESIDENTIAL _____% COMMERCIAL _____%

    New Construction _______% New Construction _______%

    Remodeling/Repair _______% Remodeling/Repair _______%

    Other _______________________ _______% January 2002 (rev. 05/01/05) 1

10. 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:

    Type of Work % % Type of Work % % Type of Work % %

    Direct Subbed Direct Subbed Direct Subbed Airport Runways Excavation Roofing

    Seismic/Retrofitting Blasting HVAC Bridge Building Grading Sewer Carpentry Insulation Steel/Structural Concrete Maintenance Steel/Ornamental Demolition Masonry Street/Road Drilling Mechanical Supervisory Only Drywall Painting Traffic Signals Earthquake Plastering Water/Gas Mains Electrical Plumbing Other:

    11. Describe your four largest projects over the past five years, including values:

    _____________________________________________________________________________________

    _____________________________________________________________________________________

    _____________________________________________________________________________________

    ____________________________________________________________________________________

12. List current projects currently underway or planned for the next year, including values:

    _____________________________________________________________________________________

    ____________________________________________________________________________________

    ____________________________________________________________________________________

13. How many new homes will you build from the ground up in the next year? _________

    14. Have you ever built a home from the ground up? Yes No

     A. How long ago? ______________ B. How many? _______________

15. How many additional insured endorsements do you anticipate needing in the next year? _________

    16. How many Waivers of Subrogation do you anticipate needing in the next year? _________

17. Have you allowed or will you allow your license to be used

     by any other contractor for a project on which you have worked? Yes No

     A. Has any other licensing authority taken any action against you? Yes No

18. Have you built or will you build on hillsides, terraces, landfills or

    Subsidence areas? Yes No

     If yes, please explain: __________________________________________________________

    19. Do you use scaffolding? Yes No

     If yes, please explain: __________________________________________________________

20. Have you been involved or will you be involved with blasting

    operations or any other hazardous work activity? Yes No

     If yes, please explain: __________________________________________________________

    January 2002 (rev. 05/01/05) 2

21. Do you perform synthetic stucco work (EIFS)? Yes No

    22. Do any of your subcontractors perform EIFS work? Yes No

23. Have you built/demolished or will you build/demolish

    buildings or other structures in excess of four (4) stories? Yes No

    If yes, please explain: _____________________________________________________

    24. Do you perform work above two stories in height? (other than interior remodel) Yes No

     If yes, what percentage? __________% Maximum Height? __________

     Please describe: _______________________________________________________________

    25. Do you perform any work at Airports? Yes No

    If yes, please explain: ___________________________________________________________

    26. Do you own, rent or subcontract any cranes? Yes No

    If yes, please explain: ___________________________________________________________

27. Have you been involved or will you or your subcontractors be

     involved in any removal of asbestos, PCB’s or other hazardous materials? Yes No

    28. Removal or work on fuel tanks or pipelines? Yes No

29. If you are a roofing contractor, subcontractor or performing roofing work, do you use:

    Hot Tar ______% Yes No

     Torch Down Yes No

     Modified Bitumen (HOT) Yes No

     Modified Bitumen (COLD) Yes No

     Hot Air Welding ______% Yes No

     Other: ___________________________________

    30. Do you perform any Mold Remediation Work? Yes No

    31. Do any of your subcontractors perform Mold Remediation Work? Yes No

     A. If yes, is coverage in place? Yes No

     B. Name of Carrier? _________________________________________

32. Have you performed or will you or your subcontractors perform

     any work below grade: Yes No

    Maximum Depth: _________Feet % of operations: ________

    33. Any shoring, underpinning, cofferdam or caisson work? Yes No

     If yes, please explain: _______________________________________________________

34. Have you worked or will you or your employees work under

     U.S. Longshoremen’s and Harbor Workers Act or Jones Maritime Act? Yes No

    35. Do you have a formal safety program in place? Yes No

January 2002 (rev. 05/01/05) 3

36. Will any work involve the construction of or involvement with

    Condominiums or Townhouses? Yes No

     A. If yes, is the work new construction? Yes No

     B. Repair or Remodel only? Yes No

    37. Will any work involve the construction of or involvement with Apartments? Yes No

     A. If yes, is the work new construction? Yes No

     How many units in the ENTIRE Project? ___________

     B. Repair or Remodel only? Yes No

38. Will any work involve the construction of or involvement with new Duplexes,

    Triplexes, Fourplexes or Patio Homes? Yes No

    39. Have you ever worked in new Duplexes, Triplexes, Fourplexes or Patio Homes? Yes No

    If yes, how long ago? _______________

    40. Will you be working in any new Tracts? Yes No

     (If yes, maximum number of homes in ENTIRE Tract ________)

    41. Have you ever worked in new Condominiums/Townhouses? Yes No

     If yes, how long ago? _______________

    42. Have you ever worked in new Apartments? Yes No

     If yes, how long ago? _______________ How many units in the ENTIRE building? __________

    43. Have you ever worked in new Tract Developments? Yes No

     If yes, how long ago? _______________

     How many units in the ENTIRE development? _______________

    44. Any current Wrap-Up/OCIP Projects? Yes No

     A. Name of Carrier? _______________________________________

    45. Have you ever worked in new Assisted Living Facilities? Yes No

     If yes, how long ago? ______________ How many units in the ENTIRE building? __________

    46. Have you or will you ever convert Apartments to Condominiums? Yes No

    47. Any unusual exposures/operations not otherwise covered by this questionnaire? Yes No

    If yes, please explain: ___________________________________________________________

48. Have there been any losses, claims or suits against you in the past five years? Yes No

     a. Are there any claims or legal actions pending against any of the entities? Yes No

     b. Do any of the entities named in the application have knowledge of any pre-existing

     act, omission, event, condition or damages to any person or property that may

     potentially give rise to any future claim or legal action against them? Yes No

     c. Have you been accused of faulty construction in the past 5 years? Yes No

     d. Have you been accused of breaching a contract in the past 5 years? Yes No

     e. Have you ever filed any Mechanic Liens in the past 5 years? Yes No January 2002 (rev. 05/01/05) 4

DEFINITIONS:

EIFS -Exterior Insulation Finishing Systems multi layered exterior wall systems (which resemble

    stucco in appearance) that are used on both commercial buildings and residential homes.

GENERAL CONTRACTOR A contractor who subcontracts work to others in excess of 50% of

    total receipts, exercises primary control of the job site, and 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.

    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) 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 the Supplemental Questionnaire is to assist in the underwriting process.

    Information contained herein is specifically relied upon in determination of insurability. The undersigned,

    therefore warrants that the information contained herein (consisting of five pages) is true and accurate to

    the best of his knowledge, information and belief. The Supplemental Questionnaire, and the application to

    which it is appended, shall be the basis of any insurance policy that may be issued and will be part of such

    policy.

    Signature of Applicant:* ____________________________________________________________

Name & Title: ___________________________________________________Date: ____________

*Must be owner, executive officer or partner of the company

January 2002 (rev. 05/01/05) 5

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