ROOFING CONTRACTORS

SUPPLEMENTAL APPLICATION

BY COMPLETING THIS APPLICATION, THE APPLICANT IS APPLYING FOR COVERAGE WITH EITHER COLONY SPECIALTY INSURANCE
COMPANY OR PELEUS INSURANCE COMPANY, AN AUTHORIZED SURPLUS LINES INSURER.

Applicant Website

Street Address City State Zip Code

Contact Email Address Contact Phone

GENERAL INFORMATION
1. Date of Incorporation/Formation: Years in business under the Applicant name:
2. Have you operated under any other name(s) in the past ten (10) years? Yes No
If “Yes”, provide business names and licenses and describe the operations:

3. Years of experience in this field:

4. Contractor License Number: _ Year License Issued:
States in which you do business:
Have you ever worked in, or do you anticipate working in New York State? Yes No
Have you ever worked in, or do you anticipate working in any of the five (5) boroughs of New York City? Yes No
Have you ever worked in, or do you anticipate working in Colorado? Yes No
5. Are you a NRCA (National Roofing Contractors Association) member? Yes No
6. Total number of employees: _ Number of leased employees:
Is Worker’s Compensation coverage in place for all of these employees? Yes No
7. Percentage of roofing operations receipts to total receipts: _%
8. Applicant is a (% of each): General Contractor _% Subcontractor % Construction Manager _ %
Describe all operations in detail:

9. Exposure Data:
Gross Receipts Payroll Subcontractor Costs
Projections for the upcoming year $ $ $
Estimate for the year just completed $ $ $
st
Actual for the 1 prior year $ $ $
nd
Actual for the 2 prior year $ $ $
rd
Actual for the 3 prior year $ $ $

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10. Percentage of roofing operations (Each line must total 100%):
Residential % New Construction - Residential %
Commercial % New Construction - Commercial %
Industrial % Remodeling/Re-roofing %
Other: % Repair %
Total 100% Total 100%

11. Indicate percentage of each:

Slope Percentage of Work
Pitched - steepest pitch: _ _ %
Low Slope %
Flat %
12. Indicate percentage of each:
Percentage of Percentage of
Type of Roofing Method of Roofing
Work Work
Asphalt Shingle % Torch Down %
Wood/Shake Shingle % Hot Air Welding %
Slate % Modified Bitumen (hot) %
Tile % Modified Bitumen (cold) %
Metal % EPDM (hot) %
Polyurethane Foam % EPDM (cold) %
Hot Tar % Other: %

PROJECTS/OPERATIONS INFORMATION
1. List all major projects completed within the past five (5) years, including work in progress and planned projects or attach a
project list:
Project Name Date Description Location Cost

2. What is the average dollar value of a completed project? $

3. Is scaffolding owned, rented, or erected? Yes No
Are other contractors at job site allowed to use it? Yes No
Do you require all persons who set scaffolding to have “competent person” certification Yes No
from OSHA?
4. Do you rent cranes from others? Yes No
If “Yes”, are they rented: with operators without operators
If rented “without operators”, what are the qualifications of your employee(s) who operate(s) the anes?
cr

Do you obtain a hold harmless agreement in your favor from the crane company as well as Yes No
additional insured status on the crane company’s general liability policy?
5. Maximum number of stories at which work is done: _

AC-SUP096-0718 Page 2 of 5
6. Do you have a formal written safety program in operation? Yes No
Please explain and/or provide a copy:

7. Have you worked or will you or your employees work under USL&H or Jones Act? Yes No
8. Indicate the type of security used on a project: Fencing Lighting Watchman
9. Indicate the safety measures used for all jobs: Sidewalk Bridges
Toeboards or slide guards on all scaffolding
Barricades fully enclosing the work area
10. Do you perform roof tear off operations? Yes No
Do you subcontract roof tear off operations to others? Yes No
11. Describe your weather detection procedures:

12. Do you have a procedure for limiting the amount of roof to be opened at a time? Yes No
If “Yes,” please describe:

13. Are there circumstances under which you will leave an unattended and “open roof” Yes No
for a period of more than two (2) hours? If “Yes”, please describe (include procedures used to protect an “open roof”):

14. Heat Application Roofing Operations

a. Do you perform any Heat Application Roofing Operations, including but not limited to Hot Tar, Yes No
Torch Down, Hot Air Welding or use any equipment that has an open flame or produces heat or sparks?
b. Do you perform any work utilizing the spraying of flammable liquids? Yes No
c. Are your employees NRCA Torch Application certified? Yes No
d. How many years of experience do you have with Heat Application Roofing Operations?
e. Is a fire watch done on all jobs after Heat Application Roofing Operations are used? Yes No
If “Yes”, please describe:

f. How long do you remain on the job after the cessation of Heat Application Roofing Operations?
g. Is there a maintenance contract in place for all tar kettles? Yes No
If “Yes”, how often are they serviced?
15. Have you ever worked on the conversion of apartments to condominiums? Yes No
16. Will your upcoming work involve new construction on condominiums? Yes No
If “Yes”, what is the percentage of total roofing operations? %
Will your upcoming work involve repair or remodel work on condominiums? Yes No
17. Will your upcoming work involve new construction on tract home developments? Yes No
If “Yes”, advise the maximum number of homes in the entire tract development?
18. Will your upcoming work involve new construction on townhouses? Yes No
Will your upcoming work involve repair or remodel work on townhouses? Yes No
19. Will you do work for a stalled, abandoned or otherwise interrupted construction project? Yes No

AC-SUP096-0718 Page 3 of 5
SUBCONTRACTOR INFORMATION/RISK TRANSFER
1. Do you use Subcontractors? Yes No
If “Yes”, what percentage of work is subcontracted? _ %
2. Does the type of subcontracted work include the following (check all that apply):
Residential Roofing Framing Siding
Commercial Roofing Plumbing Welding
Torch Down Application Sheet Metal Heating/AC
Hot Tar Application Gutters Demolition
Window Installation Debris Removal
3. Do you utilize AIA standard contracts for all of your subcontractors? Yes No
4. Are all subcontractors required to sign a hold harmless and indemnification Yes No
agreement in your favor? If “No,” please explain:

5. Are Certificates of Insurance obtained from subcontractors? Yes No

General Liability Minimum Limits Required: _ _
Workers Compensation Minimum Limits Required: _ _ _
6. Are you named as an additional insured on all subcontractors’ policies? Yes No
7. Do you allow subcontractors to begin work prior to the collection of Certificates of Insurance? Yes No
8. Do you have a procedure for reviewing and maintaining Certificates of Insurance? Yes No
9. Do you ever use uninsured subcontractors? Yes No
10. Do you normally use the same subcontractors? Yes No

OTHER OPERATIONS
1. Do you draw any plans or blueprints used in your construction work? Yes No
If “Yes”, has Professional Liability Coverage been obtained? Yes No
Limit of Liability: $ _ _
2. Do you own any vacant land (raw land with no developmental or improvement activity, held only Yes No
for investment of possible development more than twelve (12) months in the future; no buildings on the
property)?
3. Do you own any real estate development property (land with improvements – streets, roads, or Yes No
utilities, etc. completed under construction)?
4. If “Yes”, to either questions 2 or 3 how is property zoned: Residential Commercial/Retail/Industrial/Other
# of acres vacant land: _ # of acres Real Estate Dev Prop: _
5. Will you loan, rent or lease equipment to others? Yes No
If “Yes”, please describe in detail to include the annual sales from this activity (if any), types of equipment and whether it is
rented with or without operators as well as a copy of the equipment rental Contract.

6. Does the Applicant currently own or operate any other business(es) other than roofing? Yes No
If “Yes”, provide name of the business and percentage of ownership and describe the operations:

AC-SUP096-0718 Page 4 of 5
LOSS EXPERIENCE
1. Loss Summary (Please Attach hard copy loss runs) Check here if not applicable
Year Carrier Premium # of Claims Incurred Comments

2. During the past three (3) years has any company ever cancelled, non-renewed, declined or refused to Yes No
issue similar insurance to you? Missouri applicants, do not answer. If “Yes,” please explain:

3. Have you ever been involved in or are you aware of any pending litigation concerning Yes No
construction defect? If “Yes,” please explain:

4. Have you been accused of any faulty construction in the past five (5) years? Yes No
If “Yes,” please explain:

5. Have you been accused of breach of contract in the past five (5) years? Yes No
If “Yes,” please explain:

FRAUD WARNING
Any person who knowingly 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, may be committing a fraudulent insurance act, and may be subject to a civil penalty or
fine.

DO NOT SIGN UNTIL YOU HAVE READ THE CONTENTS OF THIS APPLICATION AND THE FRAUD WARNING.
I have reviewed the contents of this application and with my signature, declare that to the best of my knowledge that all
statements herein are true and no material facts have been suppressed or misstated. I am also aware that my operation may
be inspected by the Insurance Company.

SIGN AND DATE

APPLICANT’S PRINTED NAME

APPLICANT’S SIGNATURE DATE

AGENT OR BROKER’S NAME LICENSE NO.

AGENT OR BROKER’S SIGNATURE DATE

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