Contractor Questionnaire

Name*

First NameLast Name

Business Name*

Estimated Revenue for the Next Year?*

Estimated Payroll for the Next Year (W2 Employees Only)*

Business Address/ Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Select All the Lines You Need Quotes For*

AutoGeneral liabilityWorkers CompProperty

How Many W2 Employees Do You Have?*

What's the Reason You're Shopping?*

PriceAgentNonrenewal/ Cancellation

How Soon Do You Need a Quote Back?

Detailed Description of Operations*

Who Are You Currently With for Each Line of Business? (GL, WC, Auto, etc.)*

How Long Have You Been With Them?*

Have You Had a Claim on Any Policy in the Last 5 Years?*

YesNo

Please Explain the Claim(s)*

What Kind of Contractor Are You?*

Do you have any industry-specific certifications? (e.g., ISO, LEED)

Do You Subcontract Any Work Out?

YesNo

What Safety Programs Are in Place?*

OSHA ComplianceFall Prevention ProgramEarly Return to Work ProgramNone

What's the Maximum Height Employees or Subcontractors Work at?*

10ft or less10-20ft20-30ftOver 40ft

What Percent of Work is Subbed Out?*

What's the Cost(amount paid) for Subcontracted Work?*

Do All Subcontractors Carry Liability Limits Equal or Higher than Yours?*

YesNo

What Kind of Roofing Do You Install? (Metal, Asphalt, Wood Shakes, etc.)*

Any Torch Work?*

How Do Employees and Materials Get to the Roof? (Scaffolding, Ladders, Lifts, etc.)*

Any Work On the Following?*

Tract HomesTownhomesApartmentsNone of the Above

Percent of Commercial vs Residential Work?*

Do You Need Coverage for Your Building?*

YesNo

What Types of Siding Do You Install?*

Any Window Installation?*

YesNo

Any Roofing Work?*

YesNo

Do You Use Ladders, Scaffolding, or Lifts?*

LaddersScaffoldingLiftsOther

Do You Do Any Work On the Following?*

Tract HomesTownhomesApartmentsNone of Above

What's the Cost of Subcontracted Work? (Dollar Amount)

Do All Subs Sign a Subcontractor Agreement?

YesNo

Detailed Description of Work Performed by Subcontractors

Roof Year of the Building?*

What Year was the HVAC Replaced?

What Year was the Plumbing Replaced?

What Year was the Electrical Replaced?

Do You Trim Trees?*

YesNo

How Do You Get Up to the Trees? Lifts, Boom Truck, etc.?*

List All the VINs, Year, Make, and Models for Your Vehicles

Have you had any safety violations in the past 5 years?

YesNo

If yes, please explain

I certify that the information provided in this questionnaire is accurate and complete to the best of my knowledge.

Name

First NameLast Name

Title

Signature

Date signed

Date