KAIGLER & COMPANY

Contractors Questionnaire
You may fill out the following form online, or print it out and fax it to us at 615-376-0799.

1. Name Insured:

2. Separately list all operations of each named insured, when entity began and, if new, note any related prior experience.

3. Percentage of Operations as:

General Contractor:%

Sub Contractor:%

Owner/Builder:%

4. Describe the types of projects in which the insured specializes: 

5. Describe the types of projects in which the insured has performed:

6. List each  project scheduled to commence over the next twelve months: (Attach separate sheet if necessary.)

Location

Start Date

Ending Date

FCV - Hard Costs

FCV-Soft Costs

Location

Start Date

Ending Date

FCV - Hard Costs

FCV-Soft Costs

Location

Start Date

Ending Date

FCV - Hard Costs

FCV-Soft Costs

Location

Start Date

Ending Date

FCV - Hard Costs

FCV-Soft Costs

7. The expected types of Construction as percentages of total values are:

Frame:

Fire Resistive:

Other:

8. Indicate the type of security to be used for each project:

Fencing

Details (Type, perimeter, height, gates, etc.)

Lighting

Details (Flood, street, distance from project)

Watchman

Details (On site, drive by service/frequency)

9. Brush Exposure?yes no

 If yes, provide details of clearance to protect perimeter

10. Does the insured currently or in the past build on hillsides, slopes, landfills or in subsidence areas? yes no

If yes, full details please.

11. Does the insured do any other work over two stories in height from grade?yes no

Maximum stories

Percentage of Work

12. Does the insured do any work below grade? yes no

Maximum depth

Percentage of total work

13. Indicated the anticipated percentage of construction work over the next twelve months performed by the insured using percentage of payroll under "direct" and percentage of contract costs under "subbed" as the basis:

Direct / Subbed

Blasting% %

Bridge Building% %

Carpentry% %

Concrete% %

Demolition% %

Drilling% %

Electrical% %

Excavation% %

Grading% %

Insulation% %

Maintenance% %

Masonry% %

Mechanical% %

Painting% %

Plastering% %

Plumbing% %

Sewer% %

Steel (structr.)% %

Street/road% %

Supervisory only% %

Water/gas mains% %

Other (describe)% %

14. Estimates Annual Direct Payroll   $

Contract Costs   $

Gross Receipts   $

15. Prior Years:

Year

Direct Payroll   $

Contract Costs   $

Gross Receipts   $

Year

Direct Payroll   $

Contract Costs   $

Gross Receipts   $

Year

Direct Payroll   $

Contract Costs   $

Gross Receipts   $

16. Indicate the percentage of construction work performed by the insured:

New Construction

Residential

Commercial

Outside

Inside Building

Building

Remodeling

Other 

17. Is the insured named as an additional insured on all subcontractors policies ?yes no

18 Are certificates of insurance obtained from subcontractors yes no

Limits required:

19. Are written contracts, including a hold harmless in favor of the insured, required of subcontractors yes no

20. Does the insured have any operations other than contracting ? yes no

If yes, explain:

21. Dollar value of average job completed     $

22.  Attach list of major jobs completed within the last five years, include work in progress and projects planned.

23. During the past three years, has any company ever canceled, declined or refused to issue similar insurance to the applicant. yes no

24. Enclose completed Accord Commercial Insurance Application and Commercial General Liability Section both of which are required to complete this application.

Name of Assured:

Title of Assured:

Name of Retail Agent:

Title of Retail Agent:

SIGNED PROPOSAL FORM

It is understood and agreed that the Signed proposal form, by the Assured, forms part of this policy and that underwriters hereon shall rely upon the information to determine the acceptability, rates and coverage.

It is further understood that any misrepresentation or omission shall constitute grounds for immediate cancellation of coverage and denial of claims, if any.

It is further understood that the applicant and/or affiliated company is under a continuing obligation immediately to notify his underwriters through his broker of any material alteration to information given.

SUMMARY APPLICATION

1. Estimated Exposure Base for the Next 12 Months

a) Total Payroll  $

b) Gross Receipts  $

2. Currently Valued Loss History - "Ground-up" Past Five Years. 100% Amount of Incurred Losses

Year
v

Paid Losses

Outstanding Losses

Incurred

No. of Losses

Year
v

Paid Losses

Outstanding Losses

Incurred

No. of Losses

Year
v

Paid Losses

Outstanding Losses

Incurred

No. of Losses

Year
v

Paid Losses

Outstanding Losses

Incurred

No. of Losses

Year
v

Paid Losses

Outstanding Losses

Incurred

No. of Losses

3. Individual Losses in Excess of $10,000

In order to fully complete this Summary, please provide information on a separate sheet.  

a) Details and full amount of each loss in excess of $10,000

b) Details and full reserve amount of each open bodily injury loss which involves serious injuries.

Serious Injuries are defined as: death, paralysis, paraplegia, quadriplegia, back injury, nerve injury or neurological deficit, brain damage, total or partial loss of limb, or loss of us a limb, fracture of limb, sensory organ or reproductive organ loss or impairment, substantial disability or disfigurement, burns, any claim for medical bills which may involve payment in excess of $25,000 from ground up.

Job List

Show Jobs, new or ongoing expected for the next 12 months. Type, Size, and State.

This Application Submitted By:

Name:

Company:

Address:

Street:

City:

State:

Zip Code:

Phone:

Fax:

E-mail (required):


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