Strickland General Agency, Inc
ROOFING CONTRACTORS SUPPLEMENTAL QUESTIONNAIRE
(Complete in Addition to Acord Application)
1. Name of Applicant:
(Complete one questionnaire for each named insured / for each risk.)
2. Percentage of Work Performed on:
Apartments
Condominiums
Explain other:
%
%
Maximum percentage of
Condominiums/Townhouse:
Industrial Buildings
One/Two Family Dwellings
work
per
year
%
%
%
Office Buildings
Other
applicant has done in past
Largest Complex (# of units):
ten
%
%
years
on
3. Percentage of work which is:
% Repair/Patch Work
% New Roofs
%
a. Reroofs
% 4 to 5 Story
% Over 5 Story
%
b. 1 to 3 Story
% Wood shake/shingle
% Composition
%
c. Slate/Tile
% Polyurethane Foam
% Metal/Aluminum
%
Hot/Composition
% Explain Other:
Other
% Pitched
%
d. Flat
Yes
No If yes, what percentage is “Hot Tar” work
%
4. Does applicant use “Hot Tar”?
Yes
No If yes, what estimated annual cost of subs
Does applicant sub out “Hot Tar” work?
for “Hot Tar” work? $
5. Does applicant install roofing systems that require use of setting fire (torch work) to asphalt for application of
Yes
No
If Yes, describe process and percentage of work
other roofing materials?
involving this?
6. Does applicant use any spray method for applying roofing materials?
Yes
No
flammable liquids or catalysts used?
Yes
No If yes, are
7. Does applicant install any type of elastomer roof coverings requiring spraying or use of flammable liquid or
Yes
No
open fires?
8. Are all jobs inspected by a foreman or the contractor at completion before leaving job site?
Yes
No
9. Which of the following does applicant use?
Yes
No Kettles
Yes
No Roof cleaning Tractors
Cranes
Yes
No Forklifts
Yes
No Scaffolding
Hoists
a. If risk involves heating kettles, are they equipped with automatic shut off valves?
10. Does applicant sub out any work?
cost:
Yes
Yes
Yes
Yes
No
No
No
No, If yes, describe type of work subbed and total annual
Does applicant obtain certificates of liability insurance from sub-contractors?
If yes, what limits are required?
Yes
No
11. Property damage resulting from water, rain, snow, sleet or ice is excluded. However, this exclusion does not
apply to the Products - Completed Operations hazard (coverage available only after job is completed). Work
on buildings over five (5) stories is also excluded.
Yes
No
Do you wish to buy back water damage (while job is in progress)?
12. Coverage also is excluded for the following: (indicate whether applicant wishes to buy back any of the
following coverages.)
Use of “Hot Tar”
Use of subcontractors
Yes
Yes
No
No
Medical Coverage
Work over 3 stories
13. Do you have knowledge of any occurrence which might give rise to a claim?
Yes
Yes
No
No
Yes
No
If yes, explain:
14. Remarks:
If coverage is provided, it will contain special exclusions (above and beyond normal policy exclusions) including,
but not limited to the following:
A. Absolute bodily injury exclusion to applicant’s employees
B Broad Form Contractual (Limited and Intermediate form is provided)
C Medical Payments Coverage (an optional coverage can be purchased for an additional premium).
D Pollution (Absolute)
E
Pre-existing Injury or Damage
F
Punitive Damages
G Use of “Hot Tar” (can be deleted for additional premium charge)
H Use of subs unless subs provide Certificate, prior to entering jobsite, showing evidence of liability
coverage equal to applicants and Worker’s Compensation Coverage.
I.
Water damage while the job is in progress (can be deleted for an additional premium).
J. Work over three (3) stories(can be changed for an additional premium).
K. Work on Condominiums, Townhomes, Townhouses or Apartments (can be deleted for an additional
premium).
The Applicant, Agent and/or Broker represents that the above statements and facts are true and that no material
facts have been suppressed or misstated.
Completion of this form does not bind coverage or commit the company to policy issuance.
Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer,
submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud
Applicant:
Producer:
Signature:
Date:
Producer Signature:
Strickland General Agency, Inc
Roofer
Quote
Bind
Agency Name:
SGA Broker Number:
Effective Date:
Name of Applicant:
Applicant Address:
Individual ____
Partnership ____
Phone #:
Corporation ____
Sub "S" ____
Legal Liability LLC ____
Joint Venture ____
Complete Description of ALL OPERATIONS you perform:_____________________________________________________
Limit of Liability:
Each Occurrence
General Aggregate
Products and Completed Operation
Owners/Partners/Officers: Number ______
Personal Advertising & Injury
Damage to Rented Premises
Medical Expense (any 1 person)
Location Address:
Current payroll of employees (other than owners):
Full Time: ____________ Part Time: _____________
Total Annual Payroll: ________________ Total Cost of Sub-Contractor work: _________________
Previous Carrier:
Prior policy dates: _________________________
Losses last three years, must give amount and full description. If more than one (1) attach company loss runs.
Do you or any of your employees or sub contractors perform ANY SPRAY PAINTING? _________________ .
1.
2.
3.
4.
5.
Name on License:
Contractor's License Number:
What state are you licensed in?
How many years has this specific business entity operated under current name? _______
How many total years experience in current contracting business does current management have? ________
If yes, attach a sample.
Is written contract developed with each and every customer?
Y / N ______
6.
What percent of your revenues over the past 5 years have been derived from your work as:
a. General Contractor
%
d.
Artisan or Subcontractor
b. Residential Contractor
%
e.
Commercial Contractor
c. Project Manager
%
f.
Real Estate Developer
7.
If the applicant is a Residential Builder, how many homes are scheduled to be built this year?
Are the homes indicated above in the same subdivision?
Y / N ______
8.
What percent of your revenues over the past 5 years have been derived from: (Totaling 100%)
New Construction
%
Remodeling
%
Repair/Maintenance
%
%
%
%
Equipment Used:____________________________________________________________________________________
9.
During the past 5 years, have you or your subs performed any work over two (2) stories tall?
If Yes, describe:
10.
Any cranes owned or rented?
If Yes, describe:
11.
During the past 5 years, have you or your subs performed any work below 4' in depth?
If Yes, describe:
Y/N
12.
Are there written contracts between you and every sub-contractor used?
Y/N
04-2008
Y/N
Y / N _______
13. Provide employee payrolls, sub contract costs and company sales for past three (3) years & estimate
for the next twelve (12) months:
Employee
Sub-Contractor's
Company
Payroll
Costs
Gross Sales
Year
$
$
$
$
$
$
$
$
$
14. Do you obtain certificates of insurance from subs for General Liability insurance?
$
If yes, what Limits do you require?
Y/N
15. Are certificates obtained from subs before you let them on to job site?
Y/N
16. Do you have knowledge of any occurrence which might give rise to a claim?
If Yes, explain:
Y/N
17. Do you have a formal safety program?
a.
Is it in writing?
b.
Who is responsible for safety within the company?
c.
Are all accidents investigated to establish the cause of loss?
d.
Have you been inspected by OSHA in the past three (3) years?
1. If yes, were these inspections in response to complaints?
2. Were you cited as a result of these inspections?
Explain any yes answer:
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
18. Have you ever been involved in or are you aware of any pending litigation against you?
If yes, please explain. _______________________________________________________________________________
19. Have you ever, do you currently, or do you intend to be involved in new construction (including site preparation) on
the following?
Yes
Yes
No
No
Nursing Homes
Apartments
Condominiums
Hospitals
Hotel/Motels
Multi Family Habitational
Day Care
Single Family Construction
20. Indicate the following types of work performed by your employees and by your sub-contractors:
E - Employees S - Sub-contractors N/A - Not Applicable
E
S
N/A
E
Carpentry
Landscaping
Concrete
Masonry
Electrical
Painting
Excavation
Plastering or Sheetrock-inside
Debris Removal
Plumbing
Demolition
Stucco or Plastering - outside
Drywall/Wallboard
Tile or wood flooring
Framing
Grading
Other (describe)
S
N/A
Premium Finance Option: 30% Down Payment $_________ Payment Options: (3 / 6 / 8 pay) consecutive payments.
I hereby authorize Strickland General Agency, Inc to sign on my behalf premium finance agreements financing the premium for the policy(ies) for which I am applying and to sign
premium finance agreements financing the premium for renewals or rewrites of such policy(ies) and I understand said premium finance agreements contain power of attorney
enabling the premium finance company to cancel my insurance policy(ies) listed in the agreement.
Total Premium $
Signature of Applicant:
Date:
Agent Signature:
Date: