CONTRACTORS QUESTIONNAIRE

ALL QUESTIONS MUST BE ANSWERED (Attach additional paper if necessary)

1. Applicant: _________________________________________________________________________

A. Years in business under current name: _________

B. Describe your Operations: _________________________________________________________

C. Do you have any other operations active or inactive? Yes No

If yes, please explain: ____________________________________________________________

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A. New York State Applicants: Any work in the five boroughs of New York? Yes No

3. List all other business names & licenses active or inactive applicant has used in the past 10 years:
____________________________________________________________________________________

A. What were the operations? ___________________________________________________________

4. Does applicant currently own/operate any other business? Yes No

If yes, need name and percentage of ownership: ____________________________________________

What are the operations? ______________________________________________________________

5. Percentage of current operations: General Contractor ____% Subcontractor ____% Construction Mgr: ____%

6. Do you use Subcontractors? Yes No If yes, please complete the following:

A. Percentage of subcontracted work: ____________%

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7. Do you collect certificates from all subcontractors? Yes No

A. What limit is required from these subcontractors? $_____________________

8. Estimates for next 12 months:

Payroll $______________ Sub-Contract Cost $______________ Gross Receipts: $________________

4 Years Prior History if Applicable: 1st Year Gross Receipts: $________________

2nd Year Gross Receipts: $________________
3rd Year Gross Receipts: $________________
4th Year Gross Receipts: $________________
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9. Indicate the percentage of construction work preformed by you: (MUST TOTAL 100%)

RESIDENTIAL _____% COMMERCIAL _____%

New Construction _______% New Construction _______%

Remodeling/Repair _______% Remodeling/Repair _______%
Other _______________________ _______%

10. Using percentage of payroll (under Direct) and percentage of contract costs (under Subbed), indicate the anticipated
percentage of construction work you will perform over the next 12 months:
Type of Work % % Type of Work % % Type of Work % %
Direct Subbed Direct Subbed Direct Subbed
Airport Runways Excavation Roofing
Blasting HVAC Seismic/Retrofitting
Bridge Building Grading Sewer
Carpentry Insulation Steel/Structural
Concrete Maintenance Steel/Ornamental
Demolition Masonry Street/Road
Drilling Mechanical Supervisory Only
Drywall Painting Traffic Signals
Earthquake Plastering Water/Gas Mains
Electrical Plumbing Other:

11. Describe your four largest projects over the past five years, including values:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
_______________________________________

12. List current projects currently underway or planned for the next year, including values:
____________________________________________________________________________________________________
_____________________________________________________________________
____________________________________________________________________________________

13. How many new homes will you build from the ground up in the next year? _________

14. Have you ever built a home from the ground up? Yes No
A. How long ago? ______________ B. How many? _______________

15. How many additional insured endorsements do you anticipate needing in the next year? _________

16. How many Waivers of Subrogation do you anticipate needing in the next year? _________

17. Have you allowed or will you allow your license to be used
by any other contractor for a project on which you have worked? Yes No
A. Has any other licensing authority taken any action against you? Yes No

18. Have you built or will you build on hillsides, terraces, landfills or
Subsidence areas? Yes No
If yes, please explain: __________________________________________________________

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19. Do you use scaffolding? Yes No
If yes, please explain: __________________________________________________________

20. Have you been involved or will you be involved with blasting
operations or any other hazardous work activity? Yes No
If yes, please explain: __________________________________________________________
21. Do you perform synthetic stucco work (EIFS)? Yes No

22. Do any of your subcontractors perform EIFS work? Yes No

23. Have you built/demolished or will you build/demolish

buildings or other structures in excess of four (4) stories? Yes No
If yes, please explain: _____________________________________________________

24. Do you perform work above two stories in height? (other than interior remodel) Yes No
If yes, what percentage? __________% Maximum Height? __________
Please describe: _______________________________________________________________

25. Do you perform any work at Airports? Yes No

If yes, please explain: ___________________________________________________________

26. Do you own, rent or subcontract any cranes? Yes No

If yes, please explain: ___________________________________________________________

27. Have you been involved or will you or your subcontractors be

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28. Removal or work on fuel tanks or pipelines? Yes No

29. If you are a roofing contractor, subcontractor or performing roofing work, do you use:

Hot Tar ______% Yes No

Torch Down Yes No
Modified Bitumen (HOT) Yes No
Modified Bitumen (COLD) Yes No
Hot Air Welding ______% Yes No
Other: ___________________________________

30. Do you perform any Mold Remediation Work? Yes No

31. Do any of your subcontractors perform Mold Remediation Work? Yes No

A. If yes, is coverage in place? Yes No
B. Name of Carrier? _________________________________________

32. Have you performed or will you or your subcontractors perform

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 any work below grade: Yes No
Maximum Depth: _________% % of operations: ________

33. Any shoring, underpinning, cofferdam or caisson work? Yes No

If yes, please explain: _______________________________________________________

34. Have you worked or will you or your employees work under
86/RQJVKRUHPHQ¶VDQG+DUERU:RUNHUV$FWRU-RQHV0DULWLPH$FW" <HV No

35. Do you have a formal safety program in place? Yes No

36. Will any work involve the construction of or involvement with condominiums or townhouses?
Yes No
A. If yes, is the work new construction? Yes No
B. Repair or Remodel only? Yes No

37. Will any work involve the construction of or involvement with apartments? Yes No
A. If yes, is the work new construction? Yes No
How many units in the entire Project? ___________
B. Repair or Remodel only? Yes No

38. Will any work involve the construction of or involvement with new Duplexes,
Triplexes, Fourplexes or Patio Homes? Yes No

39. Have you ever worked in new Duplexes, Triplexes, Fourplexes or Patio Homes? Yes No
If yes, how long ago? _______________

40. Will you be working in any new tracts? Yes No

If yes, maximum number of homes in ENTIRE TRACT DEVELOPMENT ________

41. Have you ever worked in new condominiums/townhouses? Yes No

If yes, how long ago? _______________

42. Have you ever worked in new Apartments? Yes No

If yes, how long ago? _______________ How many units in the entire building? __________

43. Have you ever worked in new tract developments? Yes No

If yes, how long ago? _______________
How many units in the entire development? _______________

44. Any current Wrap-Up/OCIP Projects? Yes No

A. Name of Carrier? _______________________________________

45. Have you ever worked in new assisted living facilities? Yes No
If yes, how long ago? ______________ How many units in the entire building? __________

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46. Have you or will you ever convert apartments to condominiums? Yes No

47. Any unusual exposures/operations not otherwise covered by this questionnaire? Yes No
If yes, please explain: ___________________________________________________________

48. Have there been any losses, claims or suits against you in the past five years? Yes No

a. Are there any claims or legal actions pending against any of the entities? Yes No
b. Do any of the entities named in the application have 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 them? Yes No
c. Have you been accused of faulty construction in the past 5 years? Yes No
d. Have you been accused of breaching a contract in the past 5 years? Yes No
e. Have you ever filed any Mechanic Liens in the past 5 years? Yes No

DEFINITIONS:

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GENERAL CONTRACTOR±$FRQWUDFWRUZKRVXEFRQWUDFWVZRUNWRRWKHUVLQH[FHVVRIRIWRWDOUHFHLSWV
H[HUFLVHVSULPDU\FRQWURORIWKHMREVLWHDQGLVQDPHGLQWKHFRQVWUXFWLRQGRFXPHQWVDVWKHJHQHUDOFRQWUDFWRURIUHFRUG

RESIDENTIAL CONTRACTOR±6LQJOHRUPXOWLXQLWIDPLO\KRXVLQJLQFOXGLQJDSDUWPHQWVFRQGRPLQLXPVDQG
WRZQKRXVHVSODQQHGXQLWGHYHORSPHQWVDQGWUDFWKRXVLQJRUVLPLODUSODQQHGFRPPXQLWLHV

SUBSIDENCE±$Q\PRYHPHQWRIWKHODQGRUHDUWKLQFOXGLQJODQGVOLGHVPXGIORZHDUWKVLQNLQJULVLQJDQGVKLIWLQJ
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TORCH APPLIED ROOFING (MODIFIED BITUMEN)±7KLVSURFHVVZKLFKLVDOVRFDOOHGWRUFKZHOGLQJLQYROYHVD

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Page 5 of 6 VELAContQues
WRAP-UP (OCIP)±$SROLF\SURYLGLQJFRYHUDJHVIRUDOOLQWHUHVWVLQDPDMRUFRQVWUXFWLRQSURMHFW$OVRNQRZDVDQ
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WARRANTY: The purpose of the Supplemental Questionnaire is to assist in the underwriting process. Information
contained herein is specifically relied upon in determination of insurability. The undersigned, therefore warrants that the
information contained herein (consisting of five pages) is true and accurate to the best of his knowledge, information and
belief. The Supplemental Questionnaire, and the application to which it is appended, shall be the basis of any insurance
policy that may be issued and will be part of such policy.

Signature of Applicant:* ____________________________________________________________

Name & Title: ___________________________________________________Date: ____________

*Must be owner, executive officer or partner of the company

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