Burns & Wilcox
Contractor’s Questionnaire
1. Applicant _____________________________________________________________
2. A. How many years of experience do you have in the contracting business? _________
B. Years in business of entity seeking coverage? __________
C. How many years of continuous insurance coverage? ______________
3. Contractors license number _______________________________________________
4. Description of operations? ________________________________________________
________________________________________________________________________
5. What percentage of your work is:
A. Commercial / Industrial __________%
B. Residential _______%
C. Of this residential work, what percentage of this work is: (complete below)
New __________% Additions ________% Remodel ________%
Totals on Line Above should equal 100%
6. What percentage of your work is Subcontracted out? _________%
7. Do you always collect Certificates of Insurance from Subcontractors? ______ Yes_____ No
8. A. Do you require Subs to carry like limits to that of your GL policy? ______ Yes_____ No
B. Do you require Subs to name you as Add’l Insured on their GL policy? ____Yes ____ No
9. Gross Receipts: A) Next 12-months: $__________ B) Last 12-months: $__________
C) 2nd year prior: $__________ D) 3rd year prior: $__________
10. A. Number of owners/officers/partners active at jobsite? #____________
B. Payroll of employees excluding owners, officers, partners & clerical? $_____________
C. Annual Subcontracted costs: $___________________
11. Describe your three largest projects underway or planned for the next year, including values:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
12. A. Have you ever performed or been involved in any new/ground up construction
projects involving condominiums, townhouses or single family
homes? _________ Yes ___________ No
B. As a Subcontractor, any involvement with the above? _______Yes _________No
C. If Yes, (on A or B) was this work only on custom homes? ______ Yes ______No
13. If you have performed work in the past on new custom homes what was the maximum
number of homes worked on per year? _____________________
B & W Supplemental Questionnaire Page 1 of 2 (rev. 07/09)
14. Will you perform work on Single Family Dwellings NEW CONSTRUCTION (not
remodel or additions) _____________ Yes _________________ No
15. A. Have you been accused of faulty construction in the past 5-years? ____Yes ___No
B. Are there any claims or legal actions pending against you? _____ Yes _____ No
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 an entity named in the application? ___ Yes ___ No
D. If any yes answers to above A, B or C, please explain on separate sheet.
16. A. Have you or will you perform work related to the following: Refineries, Chemical
Plants, Hospitals or Prison work? _______ Yes __________ No
B. If yes, please explain.
17. Have you or will you work as a construction manager for a fee? _____ Yes ____ No
18. Are you a residential roofing contractor (other than roof work in conjunction with a
remodel or addition being done by you)? ______ Yes ______ No
19. A. Do you have other operations other than contracting? _______ Yes ______ No
B. If yes, are these operations to be covered by this Insurance? _____ Yes _____ No
C. Please provide details of these other operations on separate sheet.
20. Do you specialize in repairs of fire damage, water damage or mold damage?
_______ Yes _______ No
21. A. Have you been involved, are you currently involved, or will you or your
subcontractors be involved in any removal or abatement of asbestos, lead, PCB’s or
other hazardous materials? _______ Yes ______ No
B. If Yes, please provide details.
22. A. Have you or will you perform remodel work on condominium units?
______ Yes ______ No
B. If Yes, will work be for single owners/single units? ______ Yes ______ No
C. Or, will work be for whole associations? ______ Yes ______ No
23. A. Does applicant use cranes? ______ Yes ______ No
B. Does applicant perform excavation work? ______ Yes _______ No
C. Are you an excavating or grading contractor? ______ Yes _______ No
D. Does applicant perform blasting operations? ______ Yes ________ No
** If yes to any of the above, please explain on separate sheet.
Warning: California law requires complete and truthful information by an applicant for insurance. That
includes providing any information that would be material to your business organization, even if not specifically
asked for on this application. Your failure to provide truthful answers and all material information can result in
the insurance company electing rescind your policy. This means they will not be responsible for any claims that
are presented. To avoid such a situation, answer all of the foregoing questions truthfully and completely.
I Have Read And Understood All Of The Questions Asked And Have Provided All Information Required.
Signature of Applicant* ______________________________ Date _________________
Name and Title* __________________________________________________________
* Must be owner, executive officer or partner
B & W Supplemental Questionnaire Page 2 of 2 (rev. 07/09)
