Roofing contractors supplemental questionnaire



Download 30.35 Kb.
Date conversion17.01.2017
Size30.35 Kb.


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      % Industrial Buildings      % Office Buildings      %

Condominiums      % One/Two Family Dwellings      % Residential Tract      %

Explain other:      

Maximum percentage of work applicant has done in past ten years on Condominiums/Townhouse:     % Largest Complex (# of units):     

3. Percentage of work which is:

a. Reroofs      % Repair/Patch Work      % New Roofs      %

b. 1 to 3 Story      % 4 to 5 Story      % Over 5 Story      %

c. Slate/Tile      % Wood shake/shingle      % Composition      %

Hot/Composition      % Polyurethane Foam      % Metal/Aluminum      %

Other      % Explain Other:      

d. Flat      % Pitched      %
4. Does applicant use “Hot Tar”?  Yes  No If yes, what percentage is “Hot Tar” work      %

Does applicant sub out “Hot Tar” work?  Yes  No

If yes, what estimated annual cost of subs for “Hot Tar” work? $      

5. Does applicant install roofing systems that require use of setting fire (torch work) to asphalt for application of other roofing materials?  Yes  No

If Yes, describe process and percentage of work involving this?      

6. Does applicant use any spray method for applying roofing materials?  Yes  No

If yes, are flammable liquids or catalysts used?  Yes  No

7. Does applicant install any type of elastomer roof coverings requiring spraying or use of flammable liquid or open fires?  Yes  No

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?

Cranes  Yes  No Kettles  Yes  No Roof cleaning Tractors  Yes  No

Hoists  Yes  No Forklifts  Yes  No Scaffolding  Yes  No

a. If risk involves heating kettles, are they equipped with automatic shut off valves?  Yes  No
10. Does applicant sub out any work? Yes  No,

If yes, describe type of work subbed and total annual cost:      


Does applicant obtain certificates of liability insurance from sub-contractors?  Yes  No

If yes, what limits are required?     No, provide Uninsured Cost of Subs $     

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.

Do you wish to buy back water damage (while job is in progress)?  Yes  No

12. Coverage also is excluded for the following: (indicate whether applicant wishes to buy back any of the following coverages.)

Use of “Hot Tar”  Yes  No Medical Coverage  Yes  No

Use of subcontractors  Yes  No Work over 3 stories  Yes  No

13. Have you had an open structure claim in the last 5 years?  Yes  No

If yes, explain:      

14. Do you have knowledge of any occurrence which might give rise to a claim?  Yes  No

If yes, explain:      


15 Provide payrolls, sub contract costs and sales for past five (5) years and estimate for next twelve (12) months:

Year

Payroll

Costs

Uninsured

Subs Costs

Sales

2000/2001

$      

$      

$      

$      

2001/2002

$      

$      

$      

$      

2002/2003

$      

$      

$      

$      

2003/2004

$      

$      

$      

$      

2004/2005


$      

$      

$      

$      

Next 12 Months

$      

$      

$      

$      

The undersigned Applicant warrants that the above statements and particulars, together with any attached or appended documents or materials (“this Application”), are true and complete and do not misrepresent, misstate or omit any material facts. Furthermore, the Applicant authorizes the Company, as administrative and servicing manager, to make any investigation and inquiry in connection with the Application as it may deem necessary.

The Applicant agrees to notify the Company of any material changes in the answers to the questions on this Application which may arise prior to the effective date of any policy issued pursuant to this Application and the Applicant understands that any outstanding quotations may be modified or withdrawn based upon such changes at the sole discretion of the Company.

Notwithstanding any of the foregoing, the applicant understands the Company is not obligated nor under any duty to issue a policy of insurance based upon this Application. The Applicant further understands that, if a policy is issued, this Application will be incorporated into and forms a part of such policy.

Signature of Applicant:       _______

Date:       ______


Title (Officer, Partner):      
SIGNING THIS QUESTIONNAIRE DOES NOT BIND THE APPLICANT OR THE INSURER OR THE ADMINISTRATIVE AND SERVICING MANAGER TO COMPLETE THE INSURANCE.


CSL 7009 (01/05) Page 1 of 2






The database is protected by copyright ©hestories.info 2017
send message

    Main page