SB Contractors Form

Please complete the secure form below. Thank you, Schreiner-Blaeser

Agency Name*

Agent/Broker Name*

Agency Phone Number*

- Business Information -

Business Name*

Named Insured

First

Last

Street

City*

State*

Zip*

Contact Name

First

Last

Phone Number*

Email Address

Location Same As Address?*

Yes

Email address*

Tax ID*

Business Description (Be Specific)*

- Liability -

Occurrence Limit*

General Aggregate*

Fire Legal Limit*

Product Aggregate*

Medical Expenses*

- Location Information -

Premises Address (if different from insured address above)*

Class Code

Class Description

Territory

Building Limit

Personal Property Limit

Business Personal Property Limit Off Premises

Deductible Amount

Protection Class*

Protected

Partially Protected

Not Protected

Property Damage Deductible*

$250

$500

$1,000

Number of Full Times Employees*

Number of Full Times Owners*

Number of Part Time Employees*

Number of Part Times Owners*

Check Applicable Options

Replacement Cost Applies

Sprinklered

Theft Exclusion

- Loss History -

Any losses within the last 3 years?*

Yes

If yes, provide date*

Loss type*

Description of loss:

Amount of loss*

Does insured do more than 10% of their work out of state (not including work in CT, FL, MA, MD, NJ, NY, OH, PA, VA)?*

Yes

Does insured do any work higher than 3 stories outside?*

Yes

Are insured's gross sales greater than $1 million?*

Yes

Does the insured employ more than 5 full time employees - include owner as 1 full time? (2 part time = 1 full time)*

Yes

Does insured subcontract out more than 25% of their total operations?*

Yes

Does insured perform roof repairs, re-roofs, or tear-offs?*

Yes

Does insured sand or apply polyurethane to hardwood floors?*

Yes

Do you have past, present, or discontinued operation that involve(d) storing, treating, discharging, applying, disposing, or transporting hazardous materials?*

Yes

Are Certificates of Insurance required from contractors?*

Yes

During the last five years has any applicant been indited for or convicted of the crime of fraud, bribery, arson, or any other arson related crime in connection with this or any other property?*

Yes

Are there any bankruptcies, tax or credit liens against the applicant in the past five years?*

Yes

Are there any bankruptcies, tax or credit liens against the applicant in the past five years?*

Yes

Describe any location/business interest owned/operated by insured but not listed:*

Do you rent or loan equipment to others?*

Yes

Where do you store your tools and equipment?*

Do you do any excavation or digging?*

Yes

If yes, what machinery is used and how deep are you digging?

If you own a retail store, does installation, service or repair work account for more than 25% of receipts?

Yes

Are you involved in manufacturing, mixing, relabeling, or repackaging of products?*

Yes

Do you demolish whole buildings or structures?*

Yes

Do you do any roof repairs, tearoffs or re-roofs?*

Yes

Do you do any asbestos removal?*

Yes

Do you sand or apply polyurethane to hardwood floors?*

Yes

Do you do any snowplowing or snow removal at 1-4 family dwellings?*

Yes

If yes, percent of your annual work.

Do you do snow removal anywhere other than 1-4 family dwellings?*

Yes

If yes, percent of your annual work.

Indicate type of operation by percentage of work (should add to 100%)

Air Conditioning/Heat:

Appliance Accessory:

Cabinetry:

Carpentry:

Cleaning Carpets:

Cleaning Office, Residential

Doors and Windows:

Driveway/Sidewalk:

Drywall:

Electrical:

Exterior Painting:

Fences:

Flooring:

Interior Painting:

Landscaping:

Mason/Brick/Block:

Tile/Marble Work:

Plaster/Stucco:

Plumbing:

Underground Services:

Woodwork Furniture:

Other:

Name of prior insurance carrier for this business?

Number of years in business under the current business name?

Has any insurance carrier canceled, declined, or nonrenewed this risk in the past 3 years?

Yes

If yes, explain:

Has insured conducted business under a DIFFERENT business name other than the one listed on this application in the past 3 years?

Yes

If yes, state name of business, prior carrier

Is that business still active?

Yes

Has insured conducted business under a DIFFERENT business name other than the one listed on this application in the past 3 years?

Yes

How many active owners are there (Active meaning goes out to job sites)?

Do you hire day labor?

Yes

If yes, how many people per day?

If yes, how many days per year?

What are your gross annual sales/receipts before expenses?

What percent of your work do you subcontract out to others on an annual basis?

What percentage of your work is done in residential settings?

What percentage of your work is done in commercial settings?

What type of commercial settings do you perform work in?

Do you work out of state?

Yes

If yes, list states and percentage of work in those states.

Expiration Date*

Current Date*

Property

Current Carrier Company

Expiration Date*

Date*

Loss of Income Limit*

Building Limit*

Contents Limit*

Deductible*

List Update Year for the following:

Roof*

Electric*

Heating*

Plumbing*

Protection

Alarm CS*

Yes

Sprinklers*

Yes

Loss of Refrigeration

Other Coverages

Other Occupants

Comments:

Underwriting

Years Experience*

Years Operating the Business*

Contractors Licence Number*

Is any work performed in New York City or the 5 boroughs?*

Yes

If yes, what percent?*

Do employees use their personal vehicles for your business?*

Yes

Do you work in any of the following:*

Townhomes

Condos/Co-Ops

Row Homes

Developments of 15 or more family homes

Percentage of your work as a General Contractor*

Percentage of your work as a Sub Contractor*

Percentage of your work in Residential *

Percentage of your work in Commercial*

Percentage of your work with Renovations*

Percentage of your work with New Construction*

Does the Insured use a written contract with customers? *

Yes

If no, why?*

Does the Insured use a written contract with Subcontractors? *

Yes

If no, why?*

Do contracts contain hold harmless agreements in insureds favor?*

Yes

Are certificates of insurance obtained from all contractors?*

Yes

Is insured added as additional insured on all subcontractors liability policies?*

Yes

Does the insured have Workers Compensation in force?*

Yes

Is Architectural or Engineering Design Provided in service?*

Yes

If yes, please explain:*

Are errors and omissions coverage carried for these services?*

Yes

Would you like Errors and Omissions quote?*

Yes

Is the insured a Project Manager or Consultant?*

Yes

Has the insured been involved or will be involved in working on Condos, apartments, or Tract Housing?*

Yes

Has the insured been involved in any claims involving construction defects?*

Yes

Your business website:

Have you ever filed for bankruptcy?*

Yes

Have you operated any other business in the past 5 yrs?*

Yes

If Yes, describe names and current status?

Do you have Commercial Auto's?*

Yes

Would you like a Commercial Auto Quote?*

Yes

Would you Like a Hired/Non Owned Auto Quote?*

Yes

List any claims in the past 5 yrs and give details below:

Please provide any comments, remarks or questions below:

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Artisan Contractor