Contact Name:
Insured Name:
Address:
City:
State:
Zip:
Phone:
Fax:
Email:
Website:

How would you prefer to receive your response? Phone E-Mail
Complete Business Name:   If Partnership, list names of all partners and percent (%) of ownership:         Years in Business as this Entity:   Contractor's License No.:

1.  Description of Operations.  Please describe the nature and scope of you operations.  (Please attach copy of any brochures you use to advertise your business:

2.  Describe any discontinued operations in the past five (5) years and/or any other business ventures you would like considered for coverage:

3.  Indicate Type of Construction Performed by Applicant:  (Must Equal 100%)      Air Cond./Heating % Landscape Gardening % Steel(Ornamental) % Carpentry % Maintenance % Steel(Structural) % Concrete % Masonry % Street/Road % Drilling % Mechanical % Supervisory Only % Drywall % Painting % Tree Trimming % Electrical % Plastering % Tree Removal % Excavating/Grading % Plumbing % Tunneling % Fence % Roofing % Waterproofing % Gas Mains % Sewer % Wrecking/Demolition % Glazing % Sprinkler Installation % Others (Describe) % Insulation %

4.  Indicate Percentage of Work Performed: a. New Construction % Remodeling % Demolition % Repair % b. Commercial % Industrial % Residential % Institutional %

5.  Please complete the following for the upcoming year and the past three (3) years: 2001 Payroll Costs Subbed to Others Gross Receipts 2000 Payroll Costs Subbed to Others Gross Receipts 1999 Payroll Costs Subbed to Others Gross Receipts 1998 Payroll Costs Subbed to Others Gross Receipts

6.  Have you ever been involved or plan to be involved in any of the following construction operations: Work You Perform Work You Subcontract To Others   Yes  No Yes  No a.  Apartments (New)       b.  Asbestos       c.  Blasting/ Explosives       d.  Bridges/ Dams/ Airports       e.  Chemical Transport/ Storage       f.  Condominium/Townhouse (New)       g.  Consulting/Engineering       h.  Demolition (Ball & Chain)       i.  Drainage/Irrigation       j.  Earthquake Retro-fitting (Structural)       k.  Fire Protection/Alarm/Sprinklers       l.  Flood Control       m. Gas Lines       n.  Hillside/Slope (If yes, % of slope)       o.  Medical/Industrial Life Support       p.  Off-Shore Work       q.  Railroad       r.  Recycling/Recovery       s.  Residential New as Gen. Contractor       t.  Reataining Walls/Earth Stabilization       u.  Roofing- All Types       v.  Scaffolding Rental/ Erection       w. Sewer/ Septic Tank Cleaning       x.  Swimming Pools       y. Tank Cleaning- Hazardous       z.  Testing/Analysis       aa. Underground Petroleum Tank Removal

Comments:

Hazardous Material

Yes No 7.  Are you involved in hazardous materials clean-up? 8.  Are any of your Subcontractors involved in hazardous materials clean-up?      If answer is "Yes" to either 7 or 8 above, please answer questions 9-15 below.  Otherwise skip to  #16. 9.  Do you verify that all subcontractors handling hazardous material have in-force liability insurance coverage and are properly licensed to perform in the required capacity? 10. Do you have a written safety procedure outlining necessary action in the event of a discharge of hazardous materials? 11. Does your safety procedure require the phone number of a local emergency response team? 12. Has your firm been cited for violation of any standard or law relating to the handling of hazardous materials in the last five (5) years?       If so, please explain circumstances and corrective action(s) taken.

13. Please list all permits  held with Federal, State, County or Municipal  Governments,  including  permit numbers and expiration dates:

14. Please list all hazardous substances and the maximum quantity that you or any sub-contractor may bring to or remove from any worksite:       Substance Description Maximum Quantity Storage at Worksite Y/N

15. Please describe any incident(s) of a release of hazardous materials you have been involved with during  the past five (5) years?  Please explain circumstances and damages (if any):

16. Please list your largest jobs scheduled for the upcoming year:       Substance Description Maximum Quantity Storage at Worksite Y/N

17. Please list your five largest jobs in the past three (3) years:   Project/Location Nature of Work Contract Cost

Please explain all "Yes" answers in "Comments" section below. Yes No 18.  Any current or past projects built on hillsides or terraces?    19.  Any work on landfills or in subsidence areas?    20.  Any subsidence losses or subsidence related claims in the past five (5) years?    21.  Any work done below/grade?  a. Maximum Depth:  ft. b.  %of total work:    22.  Are all subcontractors required to carry in-force liability insurance?    23.  Do you have a written contract with your subcontractors?    24.  Are all certificates of insurance obtained and monitored?    25.  Are you named as an additional insured on your subcontractors' liability policy?        If yes, what is the minimum limit of liability required on subcontractor's policy?   Please attach any of the hold harmless or additional insured  contracts you will be required to provide to others.    26.  Are you presently aware of the act, error, omission or circumstance that may lead to a claim or lawsuit being brought against you?    27.  Are you aware of any current claim or lawsuit against another party that may lead to the  same or a similar claim or lawsuit being brought against you in the future?    28.  Has any local, state or federal government agaency or any licensing board cited you for  violation of any law or regulation or investigated you in the past five (5) years?    29.  Has any person or entity sought insurance coverage claim or lawsuit against them by insisting that they were an additional insured under a policy issued to you as the named inusred?    30.  Within the past five (5) years, has any person or entity demanded that you defend them or hold them harmless, in any claim or lawsuit?    31.  Has there ever been a lapse, restriction or cancellation of your liability insurance?

Comments:

Return to main page. Stanly Insurance Brokerage, Inc. A Member of Atlantic Pacific Insurance Brokers 244 California Street, Suite 610, San Francisco, CA 94111 Phone: 415-433-3082/800-338-7973, Fax: 415-433-3055 Mailing address is PO Box 26630, SF 94126-6630 Email: sales@stanlyinsurance.com License Number: 0B67307 Hosting by Barefoot Digital Site Design by Geoff Rapoport