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Contractors Questionnaire

  1. Contractors Questionnaire
Contractors QuestionnaireVictor Gonzalez2023-07-27T19:43:23-04:00

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Step 1 of 8

12%
Business Owner's Name*
Can we text you?
Business Address*
Do you have other business operations active or inactive?*
Have you had any other business names & licenses in the past 10 years?*
Do you currently own/operate any other business?*

Current Operation Percentages

Please enter 0 below if an operation does not apply.
Do you use Subcontractors?*
(including all of subs' labor and materials)
Do you collect certificates from all subcontractors?*

Payroll Estimates

Estimated payroll for the next 12 months. All fields are required. Please enter 0 if no payroll.

5 Years Prior History

Construction Performed By You

Please enter a number from 0 to 100.
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Estimated Types of Construction Work to Perform

Please enter the estimated percentage of construction work to be performed over the next 12 months using payroll Direct and Subcontracted.
Please enter a number from 0 to 100.
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Projects

Please enter a number greater than or equal to 0.
Have you ever built a home from the ground up?*
Have you built, or will you build, on hillsides, terraces, landfills, or Subsidence areas?*
Do you use scaffolding?*
Have you been involved, or will you be involved, with blasting operations or any other hazardous work activity?*
Do you perform synthetic stucco work (EIFS)?*
Do any of your subcontractors perform EIFS work?*
Have you, or will you, build/demolish buildings or structures in excess of 4 stories?*
Do you perform work above 2 stories in height (other than interior remodel)?*
Do you perform work at airports?*
Do you own, rent, or subcontract any cranes?*
Have you been involved or will you or your subcontractors be involved in any removal of asbestos, PCB's or other hazardous materials?*
Removal or work on fuel tanks or pipelines?*
Do you or your subcontractors perform roofing work?*
Hot Tar?*
Torch Down?*
Hot Air Welding*
Modified Bituman (HOT)*
Modified Bituman (COLD)*
Do you perform any Mold Remediation work?*
Do any of your subcontractors perform Mold Remediation work?*
Have you performed, or will you or your subcontractors, perform any work below grade?*
Please enter a number from 0 to 100.
Any shoring, underpinning, cofferda, or caisson work?*
Have you worked or will you or your employees work under U.S. Longshoremen's and harbor Workers Act or Jones Maritime Act?*
Do you have a formal safety program in place?*
Will any work involve the construction of or involvement with Condominiums or Townhouses?*
Is condo work on New Construction or Repair or Remodel only?*
Will any work involve the construction of or involvement with Apartments?*
Is apartment work on New Construction or Repair or Remodel only?*
Please enter a number greater than or equal to 0.
Will any work involve the construction of or involvement with new Duplexes, Triplexes, Fourplexes, or Patio Homes?*
Have you ever worked in new Condominiums/Townhouses?*
Have you ever worked in new Apartments?*
Have you ever worked in new Duplexes, Triplexes, Fourplexes, or Patio Homes?*
Have you ever worked in new Tract Developments?*
Any current Wrap-Up/OCIP Projects?*
Have you ever worked in new Assisted Living Facilities?*
Have you, or will you, ever convert Apartments to Condominiums*
Any unusual exposures/operations not otherwise covered by this questionnaire?*

Additional Insured(s)

Have you allowed, or will you allow, your license to be used by any other contractor for a project on which you have worked?*
Has any other licensing authority taken any action against you?*

Losses and Claims

Are there any claims or legal actions pending against any of the entities?*
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?*
Have you been accused of faulty construction in the past 5 years?*
Have you been accused of breaching a contract in the past 5 years?*
Have you ever filed any Mechanic Liens in the past 5 years?*

Finish

Consumer Disclosure*
All the above statements made by me in this form are accurate and true to the best of my ability.
Clear Signature
MM slash DD slash YYYY
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BBB A+ Rating: Allied Insurance Group in Fort Lauderdale Florida

Miami, Florida Office

16155 SW 117 Ave., #B17
Miami, Florida 33177
Phone: 866-500-2175

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7777 Davie Road Extension #200B
Hollywood, Florida 33024
Phone: 954-475-8886

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603 E. Fort King Street
Ocala, Florida 34471
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