Contractor Audit/Survey

Survey Date: Completed by:
Name on Policy: Policy #:
Address: City:
State: Zip:

Liability
 
Describe type of work performed:
 
If more than one trade, describe primary and secondary functions and % of work each constitutes.
Primary      %
Secondary      %
Length of Time in Business years
Total Years Experience in Trade(s) years
Percentage of Commercial work performed:  %
Percentage of Residential work performed:   %
Describe total experience if in business fewer than three years.
 
Is this the insureds principal employment? Yes  No
If no, what is your principal employment?   
Annual Receipts $
Annual Employee Payroll $
Annual Salary for owners $  (Subject to a minimum of $20,000.00 each)
Radius of operations    miles
Operations outside of NY State? Yes  No
If yes, please describe:
 
Number of Owners:
Number of FT Employees:
Number of PT Employees:
Do you lease employees from a leasing agency? Yes  No
If yes, how many employees do you lease?
 
Is any work subcontracted? Yes  No
If yes, list subcontractors used:
Amount paid to subcontractors in the past twelve months      $
Certificates on file? Yes  No
 
Do you rent or lease equipment to others? Yes  No
If yes, describe type of equipment:
 
 
Are you or your subcontractors involved in any of the following:
Demolition Yes  No Operations w/ flammables or chemicals Yes  No
Pesticides/asbestos Yes  No Excavation Yes  No
Exterior work over three stories Yes  No Blasting/explosives Yes  No
Roofing Yes  No General Contracting Yes  No
Snow Plowing Yes  No Tree Care Yes  No
Spray Painting Yes  No Lawn Service Yes  No
 
 
1. Are you involved in the repair, installation or servicing of the following?
Boilers Yes  No Fire/Burglar Alarms Yes  No
Sprinkler Systems Yes  No Computers Yes  No
If any of the above are yes, please describe:
2. Do you manufacture and/or sell any products that are not installed? Yes  No
If yes, please describe:
3. Are there any underground storage tanks utilized, including but not limiting locations such as shop, residence or job site? Yes  No
If yes, please describe:
4. Has any coverage been declined, cancelled or non-renewed in the past three years? Yes  No
If yes, please describe:
5. Have there been any losses in the past three years? Yes  No
If yes, please describe:
 
Briefly describe the three largest jobs you have had in the last eighteen months including the approximate dollar amount:
Job #1      $
Job #2      $
Job #3      $
 
Additional Comments:

IMPORTANT NOTICE TO POLICYHOLDER

"Any person who knowlingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation."

As part of our underwriting procedure, a routine inquiry may be made which will provide applicable information concerning character, general reputation, personal characteristics and mode of living. A Consumer Report may be requested by the insurer to which this application is assigned. Subsequent consumer reports may be requested in connection with an update, or renewal, or extension of the insurance to which this application is made. The Applicant, upon written request, will be informed whether or not a consumer report was requested – and if such was requested, informed of the name and address of the consumer reporting agency that furnished the report. The person completing this survey hereby affirms that the statements and representations made herein are true to the best of his/her knowledge.