Contractor Insurance Application, New Business Coverage

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Home
Commercial Insurance
- Business Coverages
- Specialty Industry Coverages
Contractual Risk Management
Bonds
Employee Benefits
DRONE(UAS) QUOTE
About
- About Us
- Blog
- Contact
PayNow

REQUEST A QUOTE

Contractors Business Application

1. Business Entity Name*:

2. DBA:

3. Mailing Address*:

4. Physical Address:

5. Website

6. FEIN#:

7. Year Business Started:

8. Estimated Gross Annual Revenue*

9. Main Contact Name and Title*:

10. Main Contact Email Address*:

11. Date of Renewal

12. Description of Operations*:

13. What percentage of your work is Industrial?*

14. What percentage of your work is Residential?*

15. What percentage of your work is Commerical?*

16. What % of your work is New Construction?*

17. What % of your work is Remodel/Repair?*

18. What % of your work is Single Family Custom Homes*

19. What % of your work is New Tract Homes*

20. What percentage of your work is you acting as a Construction Manager

21. What percentage of your work is you acting as Sub Contractor

22. What percentage of your work is you acting as a General Contractor

23. Do you use subcontractors?*

YES

NO

23 a. - Annual Sub Contractor Costs*

23 b. Do you have a standard formal written contract with Subcontractors?

YES

NO

23. c. Do you require all subcontractors to name you as an additional insured?

YES

NO

24 d. Does your contract with subcontractors include a hold harmless favoring you?

YES

NO

25 f. Do you require Waiver of Subrogation endorsement on CGL and W.C.?

YES

NO

26 a. Gross receipts for the next 12 months*

26 b. Gross receipts for the last year

26 c. Gross receipts for the 2nd year prior

26 d. Gross receipts for the 3rd year prior

26 e. Gross receipts for the 4th year prior

27 a. Total Payroll next 12 months*

27 b. Total Payroll last year

27 c. Total Payroll 2nd prior year

28. Describe your five largest projects over the past five years, including values:

29. Describe your two largest projects currently underway or planned for the next year, including values:

30. Will you perform work involving or related to CONSTRUCTION, on or about the premises of Condominiums or Townhouses

YES

NO

31. Will you perform work involving or related to CONSTRUCTION, on or about the premises of Apartments

YES

NO

32. Will you perform work involving or related to CONSTRUCTION, on or about the premises of Tracts, PUD’s, or any other development, premises or project with more than 150 homes built or planned:

YES

NO

33. Have you ever performed work on hillsides, hilltops, slopes, cliffs, landfill or other subsidence areas, or do you plan to in the future?

YES

NO

34. Have or will any of your projects involve caissons, cantilevers, piers, retaining walls, shoring, underpinning, or other heavy structural engineering techniques?

YES

NO

35. Do you perform work above two stories in height (other than interior remodeling)?

YES

NO

36. Do you perform any work below ground level?

YES

NO

37. Have you ever or will you build, remove, repair or replace roofs?

YES

NO

38. Have you or will you work as a construction manager on a fee basis?

YES

NO

39. In the past 3 years have you been fired or replaced on a job in progress?

YES

NO

40. Have you or will you supervise subcontractors whose payments are run through another entity?

YES

NO

41. Note: the following questions apply regardless of whether the applicant was at fault for a claim or incident, and regardless of whether the claim or incident was covered by insurance. Explain any “yes” answers in the space provided below:

YES

NO

41a. Have there been any losses, claims or suits against you in the past 5 years?*

YES

NO

41b. Are there any claims or legal actions pending against any of the entities named in the application?

YES

NO

41c. 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 any such entity?

YES

NO

41d. Have you been accused of faulty construction in the past 5 years?

YES

NO

41e. Have you been accused of breaching a contract in the past 5 years?

YES

NO

42. For each of the following activities, check:

No to all below

Free Text

Yes: if the activity has or will be performed, subcontracted, or supervised by applicant. No: if the applicant has never and does not plan to perform, subcontract, or supervise the activity.

a. LPG work

YES

NO

b. Concrete Tilt-Up Construction

YES

NO

c. Demolition

YES

NO

d. Seismic Retrofitting

YES

NO

e. Swimming Pool Construction

YES

NO

f. Boiler Installation/Repair

YES

NO

g. Industrial Machinery Repair or Installation

YES

NO

h. Use of Cranes

YES

NO

i. Rental of Equipment to others

YES

NO

j. Process Piping

YES

NO

k. Refineries

YES

NO

l. Chemical Plants

YES

NO

m. Hospitals

YES

NO

n. Road/Highway/Bridge

YES

NO

o. Underground Tank removal, repair or installation

YES

NO

p. Work on Gas Lines/Pumps

YES

NO

q. Asbestos or Lead Abatement

YES

NO

r. Environmental Cleanup

YES

NO

s. Dam or Levee Work

YES

NO

t. Traffic Signals/Control Work

YES

NO

u. Gas Stations

YES

NO

v. Airports

YES

NO

w. Public Utilities

YES

NO

x. Railroads

YES

NO

Explain any “yes” answers to Question 41, and state whether performed by insured or subcontracted:

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Business Name:

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Phone:

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Email:

customerservice@hakorisk.com

Doing business in California as Hako Risk & Insurance Services (License # 6006242)

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