Contractors Supplemental Application

Section I – Applicant Information

Name of Applicant: *

Email *

Address:

Telephone:

Website:

State(s) / Area of Operation:

Licensed for Business in State(s):

Years in Business:

Contractor License #:

Industry Experience:

Description of Operations:

Section II – Business Information

Is applicant or any proposed named insured one of the following? (Check all that apply.)

Please provide historical receipts, payroll and cost of subcontracted work.

5th Prior Year Payroll

5th Prior Year Receipts

5th Prior Year Subcontractor Costs

4th Prior Year Payroll

4th Prior Year Receipts

4th Prior Year Subcontractor Costs

3rd Prior Year Payroll

3rd Prior Year Receipts

3rd Prior Year Subcontractor Costs

2nd Prior Year Payroll

2nd Prior Year Receipts

2nd Prior Year Subcontractor Costs

Current Year Payroll

Current Year Receipts

Current Year Subcontractor Costs

Projected Next 12 months Payroll

Projected Next 12 months Receipts

Projected Next 12 months Subcontractor Costs

Payroll of owners, officers and partners active at jobsites or performing supervisory duties:

Payroll of employees other than owners, officers, partners and clerical:

Cost of leased, temporary, staffing service, casual labor (if not included above):

Does the applicant currently own or operate any other business?

Yes
No

If YES, list name and describe operations and percentage of ownership: *

List and describe operations of all other business names and licenses active or inactive that applicant has used in the last five (5) years.

Have you ever declared bankruptcy under this name or any other similar entity in which you have had a controlling interest?

Yes
No

If YES, please provide the name of each entity and the date and jurisdiction of bankruptcy. *

Section III – Contracting Operations

Please indicate your percentage of work that is:

Commercial New

Commercial Remodel

Industrial

Institutional

Mercantile

Office

Remodeling – Structural

Remodeling – Nonstructural

Other

Residential

Residential New

Residential Remodel

Apartments

Condominiums/Townhouses

Custom Homes

Tract Homes

Remodeling – Structural

Remodeling – Nonstructural

Other

Using percentage of payroll (under Direct) and percentage of contractor costs (under Subbed), indicate the anticipated percentage of construction work you will perform over the next 12 months.

Type Of Work: Airport

% Direct

% Subbed

Not Done

Not Done

Alarm Installation/Repairs

% Direct

% Subbed

Not Done

Not Done

Alarm Monitoring

% Direct

% Subbed

Not Done

Not Done

Asbestos

% Direct

% Subbed

Not Done

Not Done

Blasting/Explosion

% Direct

% Subbed

Not Done

Not Done

Boiler Work

% Direct

% Subbed

Not Done

Not Done

Bridges

% Direct

% Subbed

Not Done

Not Done

Carpentry

% Direct

% Subbed

Not Done

Not Done

Concrete Foundations

% Direct

% Subbed

Not Done

Not Done

Concrete – Other

% Direct

% Subbed

Not Done

Not Done

Dam or Levee Work

% Direct

% Subbed

Not Done

Not Done

Demolition

% Direct

% Subbed

Not Done

Not Done

Drilling

% Direct

% Subbed

Not Done

Not Done

Drywall

% Direct

% Subbed

Not Done

Not Done

Electrical

% Direct

% Subbed

Not Done

Not Done

Excavation or Grading

% Direct

% Subbed

Not Done

Not Done

Earthquake Repair

% Direct

% Subbed

Not Done

Not Done

Fireproofing

% Direct

% Subbed

Not Done

Not Done

Fire/Water Restoration

% Direct

% Subbed

Not Done

Not Done

Gas/Water Mains

% Direct

% Subbed

Not Done

Not Done

HVAC

% Direct

% Subbed

Not Done

Not Done

Insulation

% Direct

% Subbed

Not Done

Not Done

LPG Work

% Direct

% Subbed

Not Done

Not Done

Landscaping

% Direct

% Subbed

Not Done

Not Done

Masonry

% Direct

% Subbed

Not Done

Not Done

Painting

% Direct

% Subbed

Not Done

Not Done

Paving-Driveways/Parking

% Direct

% Subbed

Not Done

Not Done

Plastering/Stucco

% Direct

% Subbed

Not Done

Not Done

Plumbing

% Direct

% Subbed

Not Done

Not Done

Railroad

% Direct

% Subbed

Not Done

Not Done

Roofing

% Direct

% Subbed

Not Done

Not Done

Seismic Retrofitting

% Direct

% Subbed

Not Done

Not Done

Sewer

% Direct

% Subbed

Not Done

Not Done

Sprinklers – Fire

% Direct

% Subbed

Not Done

Not Done

Sprinklers – Landscape

% Direct

% Subbed

Not Done

Not Done

Steel – Ornamental

% Direct

% Subbed

Not Done

Not Done

Steel – Structural

% Direct

% Subbed

Not Done

Not Done

Street/Road Construction

% Direct

% Subbed

Not Done

Not Done

Swimming Pools

% Direct

% Subbed

Not Done

Not Done

Tile/Stone/Marble

% Direct

% Subbed

Not Done

Not Done

Traffic Signals/Controls

% Direct

% Subbed

Not Done

Not Done

Underpinning

% Direct

% Subbed

Not Done

Not Done

Utilities

% Direct

% Subbed

Not Done

Not Done

Window, Door & Siding

% Direct

% Subbed

Not Done

Not Done

Water Proofing

% Direct

% Subbed

Not Done

Not Done

Other

What Is Other

% Direct

% Subbed

Not Done

Not Done

Other

What Is Other

% Direct

% Subbed

Not Done

Not Done

Section IV – Other Operations

Does the applicant have any past, current or planned work involving:

Apartments or apartment conversions?

Yes
No

Assisted living facilities, retirement homes, military housing, student housing?

Yes
No

Blasting operations or any other hazardous work activity?

Yes
No

Building on hillsides, hilltops, landfills or other subsidence areas?

Yes
No

Excavation, tunneling, underground work or earth moving?

Yes
No

Exterior stucco, plaster or exterior insulation finish systems (EFIS)?

Yes
No

Gas stations, refineries, chemical plants, airports, public utilities, railroads or hospitals?

Yes
No

Medical and/or industrial life supporting piping?

Yes
No

New construction activities for multi-unit residential projects including condominiums, townhouses, row houses and other multi-family structures?

Yes
No

New construction activities for tract home subdivisions, master planned residential communities with more than 15 homes or lots?

Yes
No

Removal or remediation of asbestos, lead, PCBs or other hazardous materials?

Yes
No

Operations to remove or remediate mold or mold damage?

Yes
No

Shoring, underpinning, caisson or cofferdam work?

Yes
No

Underground storage tanks, fuel tanks or pipelines?

Yes
No

If YES to any questions above, please provide details:

Does the applicant own vacant land, real estate development property or model homes?

Yes
No

How many new homes will you build as a general contractor in the next year?

What is the largest number of new homes you have built in any one year?

Are you engaged in any “wrap ups” or owner-controlled programs?

Yes
No

If YES, please describe:

Does the applicant conduct any work in the states of New York or Colorado?

Yes
No

Has the applicant allowed or will the applicant allow his license to be used by any other contractor for a project on which the applicant has worked?

Yes
No

Do you or have you worked as a construction manager for a fee?

Yes
No

Does the applicant build, demolish or perform any exterior operations over three (3) stories in height from grade?

Yes
No

Percent of operations:

Maximum Height:

Does the applicant or applicant’s subcontractors perform any underground or below-grade work?

Yes
No

Percent of operations:

Maximum Height:

Any change in the type or scope of construction activity performed by the applicant in the past five (5) years?

Yes
No

If YES, please describe:

Does applicant have any employees working under the following?

Jones Maritime Act

Yes
No

U.S. Longshore and Harbor Workers’ Compensation Act

Yes
No

Do you employ temporary, volunteer, casual workers or uninsured subcontractors?

Yes
No

If YES, please describe:

Section V – Current Projects

Complete the following for the five (5) largest projects in progress or scheduled over the next (12) months.

Project Description

Project Value

Section VI – Past/Completed Projects

Complete the following for the five (5) largest projects in last five (5) years.

Project Description

Project Value

Section VII – Jobsite Safety

Does the applicant have a formal safety program in place?

Yes
No

Does your safety program contain the following written procedures? If yes, please check all that apply:

Does the applicant offer an orientation/training program for new or transferred employees?

Yes
No

Are all jobs inspected by management at completion before leaving the jobsite?

Yes
No

Does the applicant mandate the use of Personal Protective Equipment (PPE)?

Yes
No

Has the applicant been cited for any OSHA violations in the past three (3) years?

Yes
No

If YES, please provide details:

Does the applicant use any type of scaffolding?

Yes
No

If YES, is scaffolding:

Owned?
Rented?
Leased?

the all they

Is the scaffolding left on the jobsite for use by others?

Yes
No

Does the applicant use any of the following equipment? (Please check any that apply.)

What is the maximum height worked when using above equipment?

Does applicant rent or lease cranes, scaffolding, mobile equipment or other machinery to others?

Yes
No

What type of equipment is rented with operator?

What type of equipment is rented without operator?

Is a written agreement required from renters/lessees of the equipment?

Yes
No

Are certificates of insurance required from renters/lessees?

Yes
No

Is insured named as an additional insured on the renter’s/lessee’s policy?

Yes
No

Section VIII – Liability Controls & Risk Transfer

If the applicant is a general contractor or a developer or employs subcontractors, do you require a written contract for general liability from all subcontractors prior to being allowed on the jobsite?

Yes
No

Do these contracts include the following:

Indemnification and hold harmless agreements that protect the insured?

Yes
No

Are you named additional insured on their policies for both ongoing and completed operations?

Yes
No

Waiver of subrogation in favor of you?

Yes
No

What limits of coverage are required from these subcontractors?

Requirement for subcontractors to carry Workers’ Compensation Insurance?

Yes
No

Are certificates of insurance obtained from all subcontractors prior to starting work?

Yes
No

Who reviews and maintains the certificates?

How long are they retained after a job?

Does the applicant currently have Workers’ Compensation coverage in place?

Yes
No

Does the applicant use a written contract with Customers?

Yes
No

If YES, please provide sample contract.

If NO, please explain when not required.

Do supervisors document each stage of construction in a written format?

Yes
No

Does the applicant have a formal Home Warranty program in place?

Yes
No

If YES, please describe and provide copy:

Does the applicant provide any architectural or engineering design services?

Yes
No

If YES, please describe:

If YES, do you carry Errors & Omissions coverage for these services?

Yes
No

Limits Carried:

Section IX – Loss / Claim History

Does the applicant have any 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 any named in the application?

Yes
No

If YES, please describe:

Are there any claims or legal actions pending against any active, inactive or dissolved entities in which you have had a controlling interest?

Yes
No

If YES, please describe:

Has the applicant ever been accused of breaching a contract in the past five (5) years?

Yes
No

If YES, please describe:

Has the applicant been fired or replaced on a job in progress in the past three (3) years?

Yes
No

If YES, please describe:

Has the applicant ever been named in litigation regarding faulty construction in the past eight (8) years?

Yes
No

If YES, please describe:

Has the applicant ever had a lapse in GL coverage?

Yes
No

If YES, please describe:

service@monteleoneins.com | 631-544-4000

Contractors Supplemental Application

Section I – Applicant Information

Section II – Business Information

Section III – Contracting Operations

Section IV – Other Operations

Section V – Current Projects

Section VI – Past/Completed Projects

Section VII – Jobsite Safety

Section VIII – Liability Controls & Risk Transfer

Section IX – Loss / Claim History

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