ZOLOFRA INSURANCE AGENCY

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Contractors Liability Form

*Full Name *Physical Street Address *City *State *Zip *Website address. If none, state NONE. *Email address. If none, state NONE. *Years in business under present name: *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
If yes, please explain.
*Employee Count: *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: *Provide the gross sales, payroll and subcontracted costs for the most recent 12 months: *Provide the gross sales, payroll and suncontracted costs for the 12 month period that ended 24 months ago: *Provide the gross sales, payroll and subcontracted costs for the 12 month period that ended 36 months ago: *Provide the gross sales, payroll and subcontracted costs for the 12 month period that ended 48 months ago: *Provide the gross sales, payroll and subcontracted costs for the 12 month period that ended 60 months ago: *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
*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
If yes, please explain:
*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
If yes, please explain:
*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?
Yes
No
If yes, please give details:
*Would you like a quick quote for Employment Practices Liability?
Yes
No

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Disclaimer Notice - The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.

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