1594 N. Batavia Street
Orange, CA 92867
(714) 524-4949 Office
(714) 524-4940 Fax

Contractors General Liability

Posted on | May 30, 2011 | Comments Off



1. Applicant Legal Name (required)

2. Email Address (required)

3. Mailing Address:

4. Phone (required)

5. Fax

5. How many years of experience do you have in contracting business?

6. License # (required)

7. Years in business of entity seeking coverage

8. Expiration date of current or most recent General Liability policy:

9. What percentage of work is:
(each line must add to 100%)

Other then apartments
  Apartments Commercial   Industrial   Public Works / government   Total

New Construction   Structural Remodel/Additions   Non-structural Remodels   Total

Interior work (inside structure)   Exterior work (outside structure)   Total

General Contractor   Construction Manager   Developer / Spec builder   Artisan Contractor   Total

10. Do you use subcontractors? If yes, complete the following:

  a) Percentage of your work subcontracted out % Annual costs Note: costs to include both cost of subcontracted labor and material

b) List the trades of subcontractors you use and give the percentage of your work they perform

% % % % % %

c) Do you always collect certificate of insurance from sub-contractors?

d) Do you always require subcontractors to name you as an additional insured?

e) Do you have a standard formal written contract with subcontractors?

If yes, does it have a hold harmless / indemnification agreement in your favor?

Note: You maybe required to provide a copy of an executed sub contract to bind coverage

f) Have the procedures listed above been followed for at least the past 3 years?

g) How long do you maintain records of the above documents?

11. Do you have any prior or planned jobs covered under "wrap-up" or OCIP policies?
Please explain

12. States in which you operate:

13. Gross Receipts not including those from wrap-up / OCIP work

Next 12 months Last 12 months 2nd year prior
3rd year prior 4th year prior

14. a) Estimated gross receipts for the next 12 months covered within an OCIP / wrap-up?

b). Please indicate total number of owners, officers and partners active
in the business or performing supervisory duties: x$33,600.00 =
  Payroll of employees other than owners, officers, partners, and clerical: $
  Cost of leased, temporary, staffing service, casual labor (if not included above) : $
  Total Payroll (sum of the above three lines) : $

15. Describe your three largest projects currently underway or planned for the next year including values

Start Date End Date Value Description

16. Describe your four largest projects over the past five years, including values

Year Completed Value Description

17. Dollar value of average job completed (including all of material, labor, and equipment): $

18. a) How many new homes will you build as a general contractor in the next year?

   b) What is the greatest number of new homes you have built in any one year?

19. How many additional insured endorsements do you anticipate needing in the next year?

20. Do any prior operations differ substantially in nature from current operations?
If Yes, explain

21. a) Are you a licensed architect or engineer? If yes, please explain
  b) Do you have any operations other then contracting?
    c) In the past 3 years have you owned, operated, or controlled any business
not listed in the application Describe:

22. Do you own vacant land, real estate development property, or model homes?

23. Note: the following questions apply to work done in any capacity, including general contractor, developer, artisian, remodeling contractor, site work contractor, supplier, etc.
Have you performed, or will you perform work involving, related to, or about the premises of:

a) Condominiums, townhouses or lofts Remodel/Repairs? New Construction?
b) Apartments Remodel/Repairs? New Construction?
c) Tracts, Planned Unit Developments,
or any other premises or project
with more than 10 homes or lots
built or planned including all phases.
Remodel/Repairs? New Construction?
d) Assisted living facilities, retirement
homes, military housing, student
housing, or any other multi unit
facility intended for permanent
habitational occupancy.
Remodel/Repairs? New Construction?


24. Have you ever performed work on hillsides, hill tops, slopes, landfill, or other subsidence areas, or do you plan in the future (other then non-structural work)

Maximum Degree of slope? Description:

25. Have or will any of your projects involve caissons, cantilevers, piers, retaining walls, shoring, underpinning, or other heavy structural engineering techniques?
If retaining walls have been or will be built, maximum height ft.

26. Do you or have you performed repairs of fire damage, water damage, or mold damage?
Percentage of operations % Describe

27. Do you perform work above two stories in height (other then interior remodeling)?
If so, what percentage? % Maximum height

28. Do you perform any work below ground level?
If so, what percentage? % Maximum depth

29. Have you or will you perform work related to the following: gas stations, refineries, chemical plants, airports, public utilities, railroad, or hospitals?

30. a) Have you or will you work as a construction manager for a fee?
  b) Have you or will you supervise contractors paid by a different entity?

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

32. Note: the following questions apply regardless of whether you were at fault for a claim or incidents, and regardless of whether the claim or incident was covered by insurance. "Legal actions" incident lawsuits, mediation or arbitration. Explain any "yes" answers below

a. Have there been losses, claims or legal actions against you in the past 5 years?
b. Are there any claims or legal actions pending against you?
c. Do you 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 entity named in the apllication?
d. Have you been accused of faulty construction in the past 5 years?
e. Have you been accused of breaching a contract in the past 5 years?

33. Have you filed for bankruptcy in the past five years?

34. For each of the following activities check:
Yes: if you have or will perform, supervise, or subcontract that activity
No: if you have never performed, supervised, or subcontracted that activity and have no plans to do so

a. demolition b. concrete tilt-up construction
c. LPG Work d. boiler installation/repair
e. elevator or escalator work f. seismic retrofitting
g. industrial machinery repair or
installation (millwright work)
h. use of cranes
i. rental of equipment to others j. EIFS work (exterior finish insulation
system or similar products)
k. playground equipment install/repair l. process piping
m. swimming pool construction n. road/highway/bridge/overpass
o. underground tank removal,
repair, or installation
p. work on gas lines or pumps
q. asbestos or lead abatement r. environmental cleanup
s. dam or levee work t. traffic signals/controls work
u. alarm installation/repairs/monitoring v. roofing installation/repairs

Explain any "Yes" answers below and state if performed by insured or a subcontractor


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