The Producer Online In Action—February 2010

March 2010, Volume 39

Return to main screen

Questionnaire Selection Coverage List

Category: Casual & Artisan Contractors Risk: Air Conditioning Contractors

GENERAL INFORMATION

Account: ____________________________________________________________________________

Account number: ______________________________________________________________________

Agency: _____________________________________________________________________________

Agency number: ______________________________________________________________________

Producer: ___________________________________________________________________________

Producer number: _____________________________________________________________________

Legal business name(s)

____________________________________________________________________________________

Mailing address :

____________________________________________________________________________________

Type of entity:

___ Individual	___ Corporation	___ Sub-S Corp.
___ Partnership	___ Joint Venture
___ Not-for-profit	___ Limited Liability Company

SIC Code(s): _________________________________________________________________________

NAICS Code(s):_______________________________________________________________________

Federal ID Number: ____________________________

When did the applicant start business operations? ___________________________________________

When did the present management assume control? _________________________________________

How many years experience does the owner have in this type of business? _______________________

How many years experience does the manager have in this type of business? _____________________

Has the applicant ever been involved in a bankruptcy procedure? ___ Yes ___ No

If yes, explain including the type of bankruptcy and the filing date.

____________________________________________________________________________________

Names of subsidiary companies or joint ventures that are not part of this application:

____________________________________________________________________________________

Important People	Name	Phone Number
Owner/Principal:	____________________________	______________
Other Decision Makers:	____________________________	______________
Plant and Grounds:	____________________________	______________
Financial:	____________________________	______________
Legal:	____________________________	______________
Claims:	____________________________	______________

The applicant’s primary operations are:

____________________________________________________________________________________

The applicant’s secondary and incidental operations are:

____________________________________________________________________________________

The applicant used to be involved in the following operations, but they have been discontinued:

____________________________________________________________________________________

The hours of operations are: _____________________________________________________________

How many days is the applicant open per week? ___

Is this a seasonal operation? ___ Yes ___ No

If yes, what is the season? From _____________ to _____________

Does the applicant have a safety program? ___ Yes ___ No

If yes, answer the following:

Name of safety director:_________________________________________________________

Phone number of safety director: __________________________________________________

Attach a copy of the safety program.

Does the applicant have a disaster plan? ___ Yes ___ No

If yes, answer the following:

Name of disaster coordinator: ____________________________________________________

Phone number of disaster coordinator:______________________________________________

Attach a copy of the disaster plan.

PROPERTY – BUSINESS PERSONAL PROPERTY

Premises # _______ Building # _______

Location address:

____________________________________________________________________________________

Describe the business personal property.

____________________________________________________________________________________

Do the applicant’s business personal property values fluctuate? ___ Yes ___ No

If yes, is the fluctuation ___Monthly ____Seasonal (from_________ to _________)

Is the business personal property:

Highly flammable: ___ Yes ___ No

Susceptible to severe damage from: ___Smoke ___ Heat ___ Water ___ Temperature

Do any of the other occupancies in this building pose a catastrophe or other hazard to the applicant (explosion, fire, chemical, other)? ___ Yes ___ No

If yes, describe.

____________________________________________________________________________________

Would business personal property be damaged if the outside heat, light or power failed? ___ Yes ___ No

If yes, answer the following:

Describe what would be damaged and how quickly.

_________________________________________________________________________________

How is the heat, light or power transmitted to the applicant?

_________________________________________________________________________________

Will alarms sound or other notification be made if power fails or shuts off? ___ Yes ___ No

Are backup generators available? ___ Yes ___ No

Are detailed records kept of all inventory, machinery, fixtures or equipment including purchase date and price? ___ Yes ___ No

Are all items labeled and assigned inventory numbers? ___ Yes ___ No

Is the customer's property shipped directly to applicant? ___ Yes ___ No

If yes, who owns the property when it is at the applicant's premises?

___ Customer ___ Applicant

Note: If the property is owned by the customer the applicant should schedule Personal Property of Others on the declarations.

BURGLAR ALARM

Describe any burglary exposures beyond what is usual to this type of business.

____________________________________________________________________________________

Describe any special features to the burglary alarm or safe or vault systems that are not noted elsewhere.

____________________________________________________________________________________

IMPROVEMENTS AND BETTERMENTS

Is the applicant a tenant? ___ Yes ___ No

If yes, answer the following.

Describe all I & B added by the applicant or for which the applicant is paying that cannot be removed.

_________________________________________________________________________________

What is the term of the applicant’s lease? ________________________________________________

What is the applicant’s lease renewal option term? _________________________________________

INLAND MARINE – ACCOUNTS RECEIVABLE

Premises # _______ Building # _______

Location address:

____________________________________________________________________________________

What is the average monthly amount of receivables over the last 12 months? ______________________

What is the maximum monthly amount of receivables during the last 12 months? ___________________

What is the estimated cost to re-create all accounts receivable records? $ _________________________

Describe the present disaster plan for reconstruction/recreation of accounts receivables.

____________________________________________________________________________________

Where are accounts receivables records stored?

____________________________________________________________________________________

What percentage of the records is duplicated and stored separately? _____%

How long are duplicates kept? ___________________________________________________________

Where and in what type of receptacles are the duplicate records stored?

____________________________________________________________________________________

INLAND MARINE – CONTRACTORS EQUIPMENT

Is there any piece of equipment that if damaged or destroyed could not be easily replaced?
___ Yes ___ No

If yes, describe.

____________________________________________________________________________________

Is there any piece of equipment that must be immediately replaced if operations are to continue?
___ Yes ___ No

If yes, describe.

____________________________________________________________________________________

Describe any unusual equipment or uses of equipment not mentioned above.

____________________________________________________________________________________

List equipment that would be replaced with different equipment if destroyed, and its replacement.

Equipment RCV Replaced by equipment RCV

____________________________________________________________________________________

Is coverage needed for employees’ tools? ___ Yes ___ No

If yes, answer the following:

What is the maximum per-tool amount and the maximum total amount exposed?

$_________________ Per tool $__________________ Total

What is the tool deductible?

$_________________ Per tool $__________________ Total

Who purchased the tools? ___ Employee ___ Employer

Are helicopters used to lift equipment onto buildings or other structures? ___ Yes ___ No

If yes, describe when used and the type of equipment moved.

____________________________________________________________________________________

INLAND MARINE – GOODS IN TRANSIT

Describe owned property or property of others that is transported by any mode of transportation, including by bicycle, car, truck, train, air or boat or sub-space transport.

____________________________________________________________________________________

If applicant transports goods in its own vehicles, describe alarms and attach copy of certificates.

____________________________________________________________________________________

If applicant transports goods in its own vehicles, are goods kept in locked conveyance (such as trunk or truck body) at all times? ___ Yes ___ No

Do employees transport applicant's goods in their own vehicles? ___ Yes ___ No

If yes, answer the following:

Describe the types of items transported.

_________________________________________________________________________________

What is the maximum value? $_______________

Do subcontractors transport applicant's goods in their own vehicles? ___ Yes ___ No

If yes, answer the following:

Describe the types of items transported.

_________________________________________________________________________________

What is the maximum value? $_______________

INLAND MARINE – INSTALLATION FLOATER

Does the applicant remove old product before installing new? ___ Yes ___ No

If yes, describe removal process and waste disposal.

____________________________________________________________________________________

Are items delivered to the customer prior to the applicant’s arrival? ___ Yes ___ No

If yes, who has legal ownership of the items until installation? ___________________________________

If the applicant retains ownership until installation is complete, describe security methods used at the jobsite.

____________________________________________________________________________________

Do more than 75% of the applicant’s receipts come from one client? ___ Yes ___ No

If yes, identify the firm, the work done for the firm, and attach a copy of the contract.

____________________________________________________________________________________

CRIME – EMPLOYEE DISHONESTY

PRIOR POLICY

Provide the policy number, carrier, limits and the inception and expiration dates of any policy that provided employee dishonesty coverage for the applicant over the last five years.

Policy

number

Carrier

Employee

dishonesty limit

Inception date

Expiration date

____________________________________________________________________________________

Note: This information is needed when a loss is discovered in the current policy year for an occurrence in prior years

EMPLOYEES

Does the applicant employ any person who has committed a theft or dishonest act? ___ Yes ___ No

Note: These employees are excluded from coverage and should not be included for rating purposes.

Are all potential employees screened prior to employment? ___ Yes ___ No

Are references required and verified? ___ Yes ___ No

Does applicant contract with another firm to lease employees? ___ Yes ___ No

Does applicant lease employees without using an outside agency? ___ Yes ___ No

Does applicant use volunteers? ___ Yes ___ No

Note: Temporary leased employees who are substituting for regular employees are covered; others, including volunteers, are excluded and should not be included for rating purposes.

MANAGEMENT CONTROLS

Does a person outside of the applicant’s accounts payable unit verify the accuracy of all monthly paid invoices?
___ Yes ___ No

Are invoices stamped "paid" at the time checks are issued to prevent duplicate checks from being issued to fictitious persons? ___ Yes ___ No

Are auditor-suggested improvements in internal controls implemented? ___ Yes ___ No

Is there adequate separation of duties between employees who:

Receive money and keep books? ___ Yes ___ No

Disperse money and keep books? ___ Yes ___ No

Reconcile bank accounts and deposit or withdraw? ___ Yes ___ No

Is jobsite ordering permitted? ___ Yes ___ No

Is there a jobsite verification of items ordered and delivered? ___ Yes ___ No

Is the jobsite verification required in order for invoices to be paid? ___ Yes ___ No

LIABILITY – GENERAL LIABILITY

ON PREMISES EXPOSURES

Describe the applicant’s on-premises operations.

____________________________________________________________________________________

Describe how the applicant disposes of waste.

____________________________________________________________________________________

Does the facility comply with the National Fire Protection Association's Life Safety Code concerning the number, size and arrangement of exits? ___ Yes ___ No

If no, explain.

____________________________________________________________________________________

Are employees instructed in proper evacuation procedures? ___ Yes ___ No

Does management conduct regular fire drills? ___ Yes ___ No

Are large panes of glass, both inside and outside, properly marked or etched to prevent accidental contact?
___ Yes ___ No

Does the applicant own, jointly own, hire or lease any watercraft or aircraft? ___ Yes ___ No

Note: If yes, there is limited or no coverage for these operations under the General Liability policy. Consider completing the appropriate Aircraft Ownership or Ship or Boat Ownership Supplement.

Does the applicant provide any child or adult care on premises? ___ Yes ___ No

Note: If yes, consider including the day care supplement.

Is food handled on premises? ___ Yes ___ No

If yes, answer the following:

Are food handlers required to use proper hygiene? ___ Yes ___ No

Has the establishment been cited by the Board of Health? ___ Yes ___ No

If yes, explain:

_________________________________________________________________________________

Does the insured store cleaning materials in a separate area distant from the food storage area?
___ Yes ___ No

Does the applicant lease equipment to others with or without operators? ___ Yes ___ No

If yes, describe the equipment and attach a copy of the lease agreement.

____________________________________________________________________________________

Does applicant lease equipment from others with or without operators? ___ Yes ___ No

If yes, describe the equipment and attach a copy of the lease agreement.

____________________________________________________________________________________

Does applicant store refrigerants on premises? ___ Yes ___ No

If yes, describe the types kept and their toxicity and flammability.

____________________________________________________________________________________

PARKING LOTS AND SIDEWALKS

Does the applicant own or rent any parking facilities? ___ Yes ___ No

If yes, answer the following:

Is a fee charged? ___ Yes ___ No

If yes, consider completing the garagekeepers questionnaire.

Does the applicant have vehicles towed when improperly parked on the premises? ___ Yes ___ No

If yes, is there a contractual agreement with the towing company? ___ Yes ___ No

If yes, attach a copy.

Does the towing company provide insurance to meet its contractual agreement? ___ Yes ___ No

Have arrangements been made for snow and ice removal from the parking lot and walkway?
___ Yes ___ No

OFF-PREMISES

Do applicant employees interact regularly with customers off-premises? ___ Yes ___ No

If yes, answer the following:

Describe the clientele by percentage.

___% Residential ___% Commercial ___% Institutional ___% Public

Do employees travel alone? ___ Yes ___ No

Are employees screened for criminal background? ___ Yes ___ No

Describe the procedure for training, monitoring and supervising all such off-premises employees.

_________________________________________________________________________________

Describe contracted work.

____________________________________________________________________________________

Is there any excavation, tunneling, underground work, or earth moving? ___ Yes ___ No

If yes, describe in detail including precautions taken.

____________________________________________________________________________________

Does applicant own, rent or use cranes? ___ Yes ___ No

If yes, explain how the cranes are used.

____________________________________________________________________________________

Does applicant flush systems? ___ Yes ___ No

If yes, describe disposal method of flushed chemicals.

____________________________________________________________________________________

Does applicant bring refrigerants onto the jobsite? ___ Yes ___ No

If yes, describe the types kept and their toxicity and flammability.

____________________________________________________________________________________

Does the applicant install products to the outside of buildings? ___ Yes ___ No

If yes, describe precautions taken to protect pedestrians.

____________________________________________________________________________________

Does the applicant weld on customer's premises? ___ Yes ___ No

If yes, describe precautions taken to prevent fires and explosion.

____________________________________________________________________________________

CONTRACTUAL EXPOSURES

Does the applicant lease the premises? ___ Yes ___ No

If yes, answer the following:

Is there a written waiver-of-rights provision for damages to property? ___ Yes ___ No

Is there a written waiver of subrogation? ___ Yes ___ No

Is there a written hold harmless agreement? ___ Yes ___ No

Are maintenance responsibilities delineated clearly in the contract? ___ Yes ___ No

Indicate under which of the following agreements the applicant has assumed liability of others:

___ Lease agreements for real estate	___ Lease agreements for signs, refrigerators, etc.
___ Sidetrack agreements	___ Contracts for electric power, steam, etc.
___ Easement agreements	___ Elevator maintenance
___ Other contracts such as construction, installation, compliance certificates, etc.

Attach a copy of each contract and/or agreement indicated above.

Is the applicant’s insurance policy required to be primary under any of the indicated contracts? ___ Yes ___ No

What are the procedures for listing the applicant as an additional insured to the contractor's policy?

____________________________________________________________________________________

Is any special insurance coverage wording required? ___ Yes ___ No

If yes, attach sample.

SUBCONTRACTORS

Does the applicant regularly use subcontractors? ___ Yes ___ No

If yes, answer the following:

Describe the type of work the subcontractors perform.

_________________________________________________________________________________

Describe procedures used to monitor the timely receipt of certificates of insurance.

_________________________________________________________________________________

Is there a written contract? ___ Yes ___ No

If yes, attach.

If no, describe the terms and agreements between the applicant and the subcontractor.

_________________________________________________________________________________

What are the subcontractors' required insurance limits? $___________

What are the procedures in place to obtain required certificates of insurance?

____________________________________________________________________________________

Percentage of work subcontracted: ____%

PERSONAL AND ADVERTISING INJURY EXPOSURES

Does the applicant advertise its products, goods or services? ___ Yes ___ No

If yes, what media are used and what is that medium’s percentage of the overall advertising budget?

___% Television	___% Direct mail	___% Radio
___% Signs	___% Newspaper	___% Yellow Pages
___% Magazine	___% Internet	___% Other

Describe other.

____________________________________________________________________________________

Does the applicant have a web page? ___ Yes ___ No

Does the applicant use an advertising firm and/or outside web designer? ___ Yes ___ No

PRODUCTS

Describe all of the applicant’s products or services.

____________________________________________________________________________________

If the product is a component part, describe the items it might become a part of.

____________________________________________________________________________________

If the product or service is defective or used improperly, describe the possible damage that could occur.

____________________________________________________________________________________

Is the applicant named on the manufacturer's policy as a vendor? ___ Yes ___ No

Does the applicant receive regular training from the manufacturer when new products are being introduced?
___ Yes ___ No

COMPLETED OPERATIONS

Who draws the plans, designs or specifications?

____________________________________________________________________________________

Who is permitted to alter plans, designs or specification?

____________________________________________________________________________________

Is the customer consulted and required to sign off prior to alterations? ___ Yes ___ No

Describe customer acceptance of project procedure and documentation.

____________________________________________________________________________________

LIQUOR

Does the applicant ever serve, sell or furnish alcoholic beverages to employees, customers
or general public? ___ Yes ___ No

If yes, is the applicant in the business of selling, distributing, or serving liquor? ___ Yes ___ No

Note: If yes, there is no liquor coverage under the General Liability policy. Consider completing the liquor liability questionnaire.

If no, what precautions are taken to prevent guests from driving while intoxicated?

____________________________________________________________________________________

Are employees and/or subcontractors permitted to drink alcohol at the jobsite? ___ Yes ___ No

OTHER PROFESSIONAL SERVICES

Is there any exposure for professional services performed by the applicant’s own personnel or through the use of subcontractors (i.e., beauty/barber shops, accounting, notary public, druggists, data processing, etc.)?
___ Yes ___ No

Note: If yes, consider completing the Professional Liability Questionnaire.

ERRORS AND OMISSIONS

Is there any exposure for errors or omissions by the applicant's own personnel or through the use of subcontractors (i.e. architects, engineers, draftsmen, etc)? ___ Yes ___ No

Note: If yes, consider completing the Professional Liability Questionnaire.

LIABILITY – EMPLOYEE BENEFITS

Does the applicant provide benefits to employees? ___ Yes ___ No

If yes, describe the benefits offered.

___Health	___Life	___ Disability	___ Stock purchase
___ Pension	___ 401(k)	___Other

Describe other.

____________________________________________________________________________________

Are the benefits available to all employees? ___ Yes ___ No

If no, who qualifies and how are the qualifications published?

____________________________________________________________________________________

Who administers the benefit programs?

____________________________________________________________________________________

If an outside firm provides services, provide a copy of the contract.

What is the employee turnover rate? ______________

Is there an established procedure for termination of an employee that includes an explanation of the benefits along with signed documentation? ___ Yes ___ No

Does the applicant help in the administration of the subcontractors' employee benefits? ___ Yes ___ No

If yes, provide a copy of the agreement.

LIABILITY – COMMERCIAL UMBRELLA

List all policies that provide liability coverages for the applicant.

Insurance coverage Primary carrier Limits

____________________________________________________________________________________

List countries where the applicant has locations and/or where employees regularly travel.

____________________________________________________________________________________

Is the applicant named as an additional insured on all subcontractors policies? ___ Yes ___ No

If yes, what are the underlying limits? _________________________________________________

Is the applicant required to name contractors as additional insureds on its policy? ___ Yes ___ No

If yes, what endorsements are used? ______________________________________________________

UNDERLYING GENERAL LIABILITY INFORMATION

List all of the exclusions attached to the underlying policy(s).

____________________________________________________________________________________

List or describe any special amendments to the underlying policy(s).

____________________________________________________________________________________

Check the coverages included.

___ Employee Benefits	___ Care Custody and Control	___ Product Recall Expense
___ Employment Related Practice	___ Underground Storage Tank	___ Stop Gap

Is there owned, hired or leased watercraft exposure? ___ Yes ___ No

If yes, describe watercraft including location and duration of exposure.

____________________________________________________________________________________

Is there owned, hired or leased aircraft exposure? ___ Yes ___ No

If yes, describe aircraft including location and duration of exposure.

____________________________________________________________________________________

What are the total annual receipts? $____________________

What is the annual cost for subcontractors: $___________________________________

UNDERLYING AUTOMOBILE LIABILITY INFORMATION

List all of the exclusions attached to the underlying policy(s).

____________________________________________________________________________________

List or describe any special amendments to the underlying policy(s).

____________________________________________________________________________________

How many vehicles of the following types are owned or leased by the applicant?

____ Private Passenger	____ Small trucks	____ Medium trucks
____Heavy trucks	____ Extra Heavy	____Bus

Are vehicles ever hired? ___ Yes ___ No

If yes, describe the vehicles hired along with the annual cost and duration.

____________________________________________________________________________________

UNDERLYING WORKERS COMPENSATION – EMPLOYERS LIABILITY INFORMATION

List all of the exclusions attached to the policy(s).

____________________________________________________________________________________

List or describe any special amendments to the policy(s).

____________________________________________________________________________________

Provide the number of employees by state.

State # State # State #

____________________________________________________________________________________

What is the total annual payroll? _________________________

AUTOMOBILE

DRIVER INFORMATION

List the names of drivers who maintain a Commercial Drivers License (CDL).

____________________________________________________________________________________

Are any officers, partners or employees furnished an automobile for their personal use? ___ Yes ___ No

Do individuals with a furnished automobile purchase automobile insurance on personally owned autos?
___ Yes ___ No

Do owned vehicles tow special equipment such as air compressors or concrete mixers? ___ Yes ___ No

Are any automobiles used in parades or other events? ___ Yes ___ No

Are any vehicles laid up for more than 30 consecutive days or more due to seasonal operations?
___ Yes ___ No

If subcontractors are used, are procedures in place to monitor the timely receipt of certificates of insurance?
___ Yes ___ No ___ No subcontractors

If yes, describe.

____________________________________________________________________________________

Are any automobiles equipped with cellular telephones, two-way radios, citizens band radios or similar devices?
___ Yes ___ No

If yes, describe.

Unit # Type Value (ACV)

____________________________________________________________________________________

How many automobiles are parked at one location overnight?

Location # of Vehicles Value

____________________________________________________________________________________

Describe lot protection.

____________________________________________________________________________________

Does the applicant lease or rent vehicles with operators to others? ___ Yes ___ No

Does the applicant lease or rent vehicles without operators to others? ___ Yes ___ No

Does the applicant travel to Canada or Mexico? ___ Yes ___ No

Do vehicles have theft alarms? ___ Yes ___ No

Does the applicant ever haul equipment for any general contractor? ___ Yes ___ No

Do employees take company trucks home? ___ Yes ___ No

If yes, answer the following:

Is the employee allowed to use the vehicle for personal use? ___ Yes ___ No

Are other family members permitted to use the vehicle? ___ Yes ___ No

Describe the circumstances that determine when an employee may take a truck home.

_________________________________________________________________________________

AUTOMOBILE – HIRED AND NONOWNERSHIP

HIRED/BORROWED AUTO

Is the applicant required to provide the primary coverage for any hired or borrowed vehicles?
___ Yes ___ No

If yes, answer the following:

Will the applicant be hiring or borrowing the same vehicle for more than six months? ___ Yes ___ No

Note: If yes, the auto should be covered in the same manner as an owned vehicle is covered.

Is the owner of the vehicle an employee of the applicant? ___ Yes ___ No

Is an employee hiring the vehicle in his or her own name in order to perform the applicant’s business?
___ Yes ___ No

List the states where the applicant may hire or borrow vehicles, and provide the estimated annual cost (put "if any" if unknown).

State Cost State Cost State Cost

____________________________________________________________________________________

Is hired auto physical damage required? ___ Yes ___ No

Are vehicles hired with drivers? ___ Yes ___ No

Describe the types of vehicles hired or borrowed and the reason the applicant hires or borrows them.

____________________________________________________________________________________

Does the applicant hire vehicles for employees when a jobsite is distant from the office? ___ Yes ___ No

If yes, answer the following:

What types of vehicles are hired?

_________________________________________________________________________________

Who is permitted to drive the vehicles?

_________________________________________________________________________________

Are employees permitted to use the vehicles for personal use? ___ Yes ___ No

NON-OWNED

What is the total number of employees at all locations? ____

If the applicant is a partnership, what is the total number of active and inactive partners? _____

What percentage of employees regularly use their own vehicles in the applicants’ business? ___%

Does the applicant want to provide Employees as Insureds coverage? ___ Yes ___ No

Do employees use their personal vehicles to provide "on demand" deliveries to homes and/or businesses?
___ Yes ___ No

What is the minimum, average and maximum distance between office and jobsite?

_________ Minimum __________ Average ___________Maximum

WORKERS COMPENSATION

OPERATIONS

List all states where the applicant anticipates working during the next twelve (12) months.

____________________________________________________________________________________

Are operations performed on public works projects outside the United States? ___ Yes ___ No

If yes, describe.

____________________________________________________________________________________

Note: Consider completing the Foreign Operations Supplement.

Are operations performed on docks, piers, wharves, etc. along navigable waters? ___ Yes ___ No

If yes, describe.

____________________________________________________________________________________

Note: Consider completing the Longshore and Harbor Workers Compensation Act and Maritime Coverages Questionnaire.

Is any work performed on barges, vessels, or bridges spanning navigable water? ___ Yes ___ No

Note: If yes, consider completing the Longshore and Harbor Workers Compensation Act and Maritime Coverages Questionnaire.

Are operations performed on fixed platforms on the outer continental shelf? ___ Yes ___ No

If yes, answer the following:

What is the closest governing state? _______________________

Where is the work located?

_________________________________________________________________________________

Describe type of work.

_________________________________________________________________________________

Note: The Outer Continental Shelf Lands Act extends the Longshore and Harbor Workers Compensation Act to apply to employees who work on fixed platforms on outer continental shelves so consider completing the Longshore and Harbor Workers Compensation Act and Maritime Coverages Questionnaire.

Are operations performed on U.S. defense bases? ___ Yes ___ No

If yes, describe.

____________________________________________________________________________________

Note: Consider completing the Defense Base Act and Federal Employers Liability Act Coverages Questionnaire.

Are operations performed in monopolistic workers compensation states? ___ Yes ___ No

Note: If yes, consider completing the Employer’s Liability - Stop Gap Questionnaire.

Does the applicant own or jointly own, operate or lease aircraft/watercraft? ___ Yes ___ No

Note: If the aircraft exposure is present, consider completing the Aircraft Ownership Supplement. If watercraft exposure is present, consider completing the Ship or Boat Ownership Supplement.

EMPLOYEES

Does the applicant employ migrant laborers? ___ Yes ___ No

If yes, describe the operation, the duties performed and the length of time employed.

____________________________________________________________________________________

Do employees ever travel outside the United States to work? ___ Yes ___ No

If yes, which countries and what is the average length of time out of country?

____________________________________________________________________________________

Note: If yes, consider completing the Foreign Operations Supplement.

Are any of the applicant’s employees considered exempt from workers compensation statutes in the jurisdiction in which they work? ___ Yes ___ No

If yes, identify the employees and the jurisdiction.

____________________________________________________________________________________

Do any employees telecommute or in other ways work out of their homes? ___ Yes ___ No

If yes, describe the employee job functions and safety procedures for them.

____________________________________________________________________________________

Does the applicant employ persons from a day labor pool? ___ Yes ___ No

If the jobsite is at a distance from the office, what percentage of the labor is local and what percentage is from the applicant's normal full-time labor force?

________% Local _______% Full time

Do the employees work higher than 13 feet? ___ Yes ___ No

If yes, describe safety measures used to prevent falls.

____________________________________________________________________________________

Does the applicant weld on the jobsite or on premises? ___ Yes ___ No

If yes, describe the training provided and the safety precautions required.

____________________________________________________________________________________

MANAGEMENT

Does the applicant obtain work permits as required by local, state or federal statutes? ___ Yes ___ No

Is there an organizational policy concerning the number of key employees who travel together? ___ Yes ___ No

If yes, attach a copy.

If the applicant employs subcontractors, how is timely receipt of certificates of insurance monitored for those subcontractors?

____________________________________________________________________________________

Is all of the machinery and equipment properly guarded and secured? ___ Yes ___ No

Are employees trained prior to operating any machinery and equipment? ___ Yes ___ No

Are employees trained in the proper cleaning techniques for machinery and equipment? ___ Yes ___ No

If yes to the training questions above, attach a copy of the training manual plus the documentation used to ensure appropriate training.

Are all walk-in freezers, cold storage boxes, and other automatic locking storage areas equipped with a pass-type latch that can be opened from the inside? ___ Yes ___ No

Are first aid kits provided? ___ Yes ___ No

Is at least one employee (on duty) trained in administering first aid? ___ Yes ___ No

Is at least one person at each jobsite trained in first aid? ___ Yes ___ No

SUPPLEMENT – SURETY REQUIREMENTS

Does the applicant provide a retirement benefit for their employees? ___ Yes ___ No

If yes, describe the retirement benefits provided.

____________________________________________________________________________________

Is the applicant required to obtain licenses or permits? ___ Yes ___ No

If yes, describe the types needed.

____________________________________________________________________________________

Are the required bonds for the retirement plan and/or the licenses or permits filed? ___ Yes ___ No

Is the applicant financially responsible for another? ___ Yes ___ No

If yes, describe the relationship and the responsibility.

____________________________________________________________________________________

Does the applicant bid for jobs? ___ Yes ___ No

If yes, describe the type of jobs.

____________________________________________________________________________________

Is the applicant required to guarantee payment for labor and supplies? ___ Yes ___ No

If yes, describe the type of exposure.

____________________________________________________________________________________

Is the applicant required to guarantee completion of a construction project? ___ Yes ___ No

If yes, describe the construction project.

____________________________________________________________________________________

Is the applicant required to guarantee their ability to supply goods and services? ___ Yes ___ No

If yes, what are the goods and services?

____________________________________________________________________________________