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| September 2007, Volume 9 |
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Questionnaire Selection Coverage List Category: Casual and Artisan Contractors Risk: Landscape Contractors GENERAL CLIENT INFORMATION Account: ___________________________________________________________ Account Number: ____________________________________________________ Agency: ____________________________________________________________ Agency Number: _____________________________________________________ Producer: __________________________________________________________ Producer Number: ___________________________________________________ BUSINESS LEGAL NAME MAILING ADDRESS _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Legal Entity: ___ Individual ___ Corporation ___ Partnership FEDERAL ID NUMBER ____________________________ YEARS IN BUSINESS ___________________________ Number of years under present management: ___ years Number of years experience of owner: ___ years Number of years experience of manager: ___ years Has the risk ever been involved in a bankruptcy procedure? ___ Yes ___ No If yes, explain: _____________________________________________________ Names of subsidiary companies or joint ventures that are not part of this application:___________________________________________________ __________________________________________________________________ IMPORTANT PEOPLE NAME OF YOUR CONTACT PHONE NUMBER _____________________________________________________________________ _____________________________________________________________________ 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 operation are: _____________________________________________ Number of days the business is open per week: _______________ Is this a seasonal operation? ___ Yes ___ No What is the season? From _____________ To _____________ Does the applicant have a safety program? ___Yes ___No Name of safety director: ____________________________________________ Phone number of safety director:_________________________________ Attach copy of safety program. Does the applicant have a disaster plan?_______ Name of disaster coordinator:_________________________________ Phone number of disaster coordinator:________________________ Attach a copy of the disaster plan.
BUSINESS PERSONAL PROPERTY PREMISES # _______ BUILDING # _______ LOCATION ADDRESS: ____________________________________________________ Describe the Business Personal Property: __________________________________________________________________________ __________________________________________________________________________ Do your Personal Property values fluctuate? ____Yes ___No If Yes, Monthly ___ Seasonally __ (from_________ to _________) Is the business personal property: Highly flammable? ___ Yes ___ No Susceptible to: Smoke __ Heat __ Water __ Temperature__ Do any of the other occupancies in this building pose a catastrophe or other hazard to your risk? (explosion, fire, chemical, other) ___ Yes ___ No Describe:______________________________________________________ _______________________________________________________________ Is your business dependent upon outside heat, light or power? ___ Yes ___ No Describe:______________________________________________________ How is it transmitted? ________________________________________ Do power sources have alarms should power fail or shut off? ___ Yes ___ No Any backup generators? ___ 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 Are chemicals stored on premises? ___ Yes ___ No If yes, answer the following questions: Describe the chemicals including their flammability and toxicity: __________________________________________________________________________ Describe storage methods: __________________________________________________________________________ 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 Description: _______________________________________________________ Term of lease __________ Renewal option ___________
CONTRACTORS EQUIPMENT Is there any piece of equipment that if damaged or destroyed cannot be easily replaced? ___Yes ___No Describe: __________________________________________________________ __________________________________________________________________ __________________________________________________________________ Is there any piece of equipment that must be immediately replaced if operations are to continue? ___Yes ___No Describe: __________________________________________________________ __________________________________________________________________ __________________________________________________________________ Is there any use of helicopters to lift equipment onto buildings or other structures? ____ Yes ____ No Describe: __________________________________________________________ __________________________________________________________________ __________________________________________________________________ Describe any unusual equipment or uses of equipment not mentioned elsewhere: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ List equipment that would be replaced with different equipment if destroyed and the replacement. Equipment RCVReplaced by equipment RCV ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Is coverage needed for employees' tools? ___ Yes ___ No If yes, answer the following questions: What is the per tool amount and the total amount? EMPLOYEE DISHONESTY PRIOR POLICY Did the applicant carry Employee Dishonesty prior to this policy? ___ Yes ___ No If yes, indicate carrier, limit and policy terms._____________________________ _________________________________________________________________ _________________________________________________________________ EMPLOYEES Does the applicant employ any person who has committed a theft or dishonest act? (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 directly? ___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. Refer to PF&M – 251.4-3 for endorsements that may be used to provide coverage for these individuals.) MANAGEMENT CONTROLS Does someone outside of the applicant’s accounts payable unit confirm correctness of all invoices paid monthly? ___ 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 improvements in internal controls, as suggested by auditors, implemented? 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
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? If no, explain ___________________________________________________________ Are employees instructed in proper evacuation procedures? 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? Does the applicant own, jointly own, hire or lease any watercraft or aircraft? NOTE: If aircraft exposure is present, consider including the Aircraft Ownership Supplement. If watercraft exposure is present, consider including the Ship Or Boat Ownership Supplement. Does the applicant provide any child or adult care on premises? 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? If yes, explain: _________________________________________________ Does the insured store cleaning materials in a separate area distant from the food storage area? Does the applicant lease equipment to others with/without operators? ___ Yes ___ No If yes, clarify: ___________________________________________________ ____________________________________________________________________ Does applicant lease equipment from others with/without operators? ___ Yes ___ No If yes, clarify: ___________________________________________________ ____________________________________________________________________ PARKING LOTS AND SIDEWALKS Does the applicant own or rent any parking facilities? If yes, answer the following: Is a fee charged? ___ Yes ___ No NOTE: If yes, consider adding Garagekeepers Questionnaire. Does the applicant exercise authority to have vehicles towed when improperly parked on the premises? If yes, is there a contractual agreement for responsibility for damage to the vehicle with the towing company? If yes, attach copy. Does the towing company provide insurance to meet any contractual agreement for responsibility of damages to the vehicle towed? Have arrangements been made for prompt removal of snow and ice from the parking lot and walkway? If located along a busy highway, are entrances and exits well defined to allow a smooth flow of traffic? OFF PREMISES Do applicant employees interact regularly with customers off premises? If yes, answer the following questions: ____Residential_____Commercial ____Other Institution Do employees travel alone? ___Yes ___ No Are employees screened for criminal background? ___Yes ___ No Describe the procedure for training, monitoring and supervising all off premises employees: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Describe contracted work: __________________________________________ ________________________________________________________________ Any blasting or explosives used? ___ Yes ___ No 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, clarify: ___________________________________________________ List all chemicals brought onto jobsite: _____________________________________________________________________ _____________________________________________________________________ How is waste from jobsite disposed? _____________________________________________________________________ _____________________________________________________________________ Does applicant have a license or permit to apply herbicides or pesticides? ___ Yes ___ No Are all employees who apply herbicides or pesticides licensed? ___ Yes ___ No If yes, describe method used to keep all licenses current: _____________________________________________________________________ _____________________________________________________________________ PROPERTY IN YOUR CARE Is there any personal property of others in the risk's care custody and control for which they may be held legally liable (i.e., automobiles, patterns, dies, property for repairs, equipment, etc.)? If yes, provide: Value $________ Description ____________________ NOTE: Consider completing the Bailees Inland Marine Questionnaire or the Garagekeepers Questionnaire for customers' items in the applicant's care, custody and control. CONTRACTUAL EXPOSURES Does the applicant lease the premises? ___Yes ___ No If yes, answer the following questions: Is there a written waiver-of-rights provision for damages to property? 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 Has applicant assumed liability of others under any of the following? Lease agreements for real estate ___ Yes ___ No Lease agreements for signs, refrigerators, etc. ___ Yes ___ No Sidetrack agreements ___ Yes ___ No Contracts for electric power, steam, etc. ___ Yes ___ No Easement agreements ___ Yes ___ No Other contracts such as construction, installation, compliance certificates, etc. Elevator maintenance ___ Yes ___ No Is the applicant’s insurance policy required to be primary (not excess) under any of the above contracts? If yes to any of the above, attach copy of contract and/or agreement. Are contracts used with outside groups or individuals for meetings, banquets, wedding receptions, etc.? If yes, attach copies. What are the procedures for listing applicant as an additional insured to the contractors policy? ____________________________________________________________________ ____________________________________________________________________ Any special wording required? ___ Yes ___ No If yes, attach sample. SUBCONTRACTORS Does the applicant regularly use subcontractors? ___Yes ___No If yes, answer the following questions: Describe the work which subcontractors perform: _____________________________ _____________________________________________________________________ _____________________________________________________________________ Describe procedures used to monitor the timely receipt of certificates of insurance: _________________________________________________________________ Is there a contract? ___Yes ___ No If yes, attach. If no, describe the terms and agreements with the subcontractor. What are the subcontractors' required insurance limits? $___________ What are the procedures to require certificates of insurance: ____________________________________________________________________ ____________________________________________________________________ Percent of work subcontracted: ________% PERSONAL AND ADVERTISING INJURY EXPOSURES Does applicant advertise their products, goods or services? If yes, what media are used? Expense % Expense % Does the applicant use an advertising firm and /or outside Web designer? PRODUCTS Describe the applicant's product(s) or service(s) provided: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 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: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Who draws plans, designs or specifications? ___________________________________________________________________________ ___________________________________________________________________________ LIQUOR Does 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? NOTE: If yes, 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: A Professional Questionnaire is provided for the classifications that have a professional exposure. Consider completing the Professional Questionnaire for the exposure.
EMPLOYEE BENEFITS Does the applicant provide benefits to employees? ___ Yes ___ No If yes, describe the benefits offered: ___Health ___Life ___ Disability ___ Other – Describe _________________________________________ If no, who qualifies and how are qualifications published? ____________________ __________________________________________________________________ Who administers the benefit programs?__________________________________ __________________________________________________________________ If an outside firm provides services, provide a copy of the contract with them. What is the employee turnover rate?_________________________________ Is there an established procedure for termination of an employee that includes an explanation of the benefits and signed documentation? Does the applicant help in the administration of the subcontractors employee benefits? ___ Yes ___ No If yes, provide a copy of the agreement. If yes, provide a copy of the pooling agreement. 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: _________________________________ If yes, what endorsements are used ? _________________________________ List all of the exclusions attached to the policy(s): _________________________________ _________________________________________________________________________ List or describe any special amendments to the policy(s): ___________________________ _________________________________________________________________________ Check the coverages included: ___Employee Benefits ___Care, Custody and Control ___Product Recall 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:___________________ ________________________________________________________________________ ________________________________________________________________________ Annual receipts: ____________________ Annual payroll: ______________________ Cost for subcontractors: _____________________________________________________ AUTOMOBILE LIABILITY List all of the exclusions attached to the policy(s): _________________________________ _________________________________________________________________________ List or describe any special amendments to the policy(s): ___________________________ _________________________________________________________________________ Types of Owned or Leased Vehicles Type # Type # Type # If yes, describe vehicles hired, annual cost and duration: ___________________________ ________________________________________________________________________ WORKERS’ COMPENSATION – EMPLOYERS’ LIABILITY List all of the exclusions attached to the policy(s): _________________________________ _________________________________________________________________________ List or describe any special amendments to the policy(s): ___________________________ _________________________________________________________________________ Number of Employees by state: State # State # State # _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Total annual payroll: __________________________
BUSINESS AUTO DRIVER INFORMATION List the names of drivers who maintain a CDL (federally required commercial drivers license): ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ Are any officers, partners or employees furnished an automobile for their personal use? Do individuals who are furnished an automobile also purchase automobile insurance on personally owned autos? Are owned vehicles used for towing special equipment (air compressors, concrete mixers, etc.)? Are any automobiles used in parades or other events? Are operations periodic or seasonal, resulting in the lay-up of any vehicles for 30 consecutive days or more? If risk employs subcontractors, are there procedures in place to monitor the timely receipt of certificates of insurance? If any yes, explain:__________________________________________________________. ________________________________________________________________________ _________________________________________________________________________ Are any automobiles equipped with cellular telephones, two-way radios, citizens band radios or similar devices? ___ Yes ___ No If yes, identify: Unit# Type Value (ACV) Location # of Vehicles Value __________________________________________________ __________________________________________________ __________________________________________________ Describe any lot protection: ____________________________________ __________________________________________________________ __________________________________________________________ Does the applicant lease/rent vehicles to others with operators? ___ Yes ___ No Does the applicant lease/rent vehicles to others without operators? ___ 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 the general contractor? ___ Yes ___ No Do employees take company trucks home? ___ Yes ___ No If yes, answer the following questions: ________________________________________________________________________ HIRED/NONOWNERSHIP Number of volunteers ___ Number of partners ___ Number of employees ___ What percentage of employees regularly use their vehicles in the applicant's business ___% Does the applicant want to provide employees as insureds coverage for the employees who use their vehicles on the applicants business?___Yes ___ No Does the applicant want to provide volunteers as insureds coverage for the volunteers who use their vehicles on the applicant’s business?___Yes ___ No Do employees use their vehicles to provide "on demand" deliveries to homes and/or businesses? ___Yes ___ No Does the applicant hire vechicles for employees when the jobsite is a distance from the office? ___ Yes ___ No If yes, answer the following questions: What types of vehicles are hired? __________________________ ______________________________________________________ ______________________________________________________ Who is permitted to drive the vehicles?______________________ ______________________________________________________ May the employees use the vehicles for personal use? ___ Yes ___ No Is the applicant required to provide the primary coverage for the vehicles hired or borrowed? ___ Yes ___ No If yes, will the applicant be hiring or borrowing the same vehicle for six months of more? ___Yes ___ No If yes, the auto should be covered in the same manner 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/her name in order to perform the applicant’s business? ___ Yes __ No List the states where the insured hires/borrows vehicles and provide estimated annual cost (put "if any" if unknown): State Cost State Cost State Cost State Cost _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Is hired auto physical damage required? ___ Yes___ No Are vehicles hired with drivers? ___ Yes ___ No Describe the type of vehicles normally hired/borrowed and the reason for the hire/borrow: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ What is the Minimum, Average and Maximum distance between office and jobsite? Minimum ______ Avg __________ Maximum ___________
WORKERS COMPENSATION OPERATIONS States where anticipated workplaces will begin within next twelve (12) months: __________________________________________________________________ _________________________________________________________________ Are operations performed on public works projects outside the United States? ___ Yes ___ No If yes, describe:____________________________________________________ _________________________________________________________________ NOTE: If yes, consider including the Foreign Operations Supplement. Are operations performed on docks, piers, wharves, etc., along navigable waters? ___ Yes ___No If yes, describe:________________________________________________ _________________________________________________________________ Note: If yes, consider including the Federal Workers/Longshore And Harbor Workers Questionnaire. Any work performed on barges, vessels, bridges over water? ___ Yes ___ No Note: If yes, consider including the Federal Workers/Longshore And Harbor Workers Questionnaire. Are operations performed on the outer continental shelf? ___ Yes ___ No If yes, describe:________________________________________________ _________________________________________________________________ Note: If yes, consider including the Federal Workers/Longshore And Harbor Workers Questionnaire.. Are operations performed on U.S. defense bases? ___ Yes ___ No If yes, describe:________________________________________________ _________________________________________________________________ Note: If yes, consider including the Federal Workers/Longshore And Harbor Workers Questionnaire. Are operations performed in monopolistic workers compensation states? ___ Yes ___ No Note: If yes, consider including the Employers Liability - Stop Gap questionnaire. Does the risk own, or jointly own with another person, partnership or corporation, operate or lease aircraft/watercraft? ___ Yes ___ No Note: If aircraft exposure is present, consider including the Aircraft Ownership Supplement. If watercraft exposure is present, consider including the Ship or Boat Ownership Supplement. EMPLOYEES Do operations involve migrant laborers? ___ Yes ___ No If yes, describe:________________________________________________ _________________________________________________________________ Do employees ever travel outside the United States to work? ___ Yes ___ No If yes, describe:____________________________________________________ _________________________________________________________________ NOTE: If yes, consider including the Foreign Operations Supplement. Are any employees exempt from workers compensation statutes in any jurisdictions in which operations are conducted? (i.e., casual laborers, volunteers, etc.)? ___ Yes ___ No If yes, describe:__________________________________________________________ ________________________________________________________________________ Do any employees predominantly work at home? ___ Yes ___ No If yes, describe employee job functions and safety procedures for those employees: ________________________________________________________________________ ________________________________________________________________________ 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 labor force? ________% Local _______% Full time Are employees required to wear masks or other equipment to protect their lungs? ___ Yes ___ No If yes, describe the equipment required: _____________________________________ ________________________________________________________________________ MANAGEMENT Does the applicant obtain work permits when the law requires them? ___ Yes ___ No Is there an organizational policy concerning the number of key employees who travel together? ___ Yes ___ No If yes, attach copy. If risk employs subcontractors, what procedure does risk use to monitor the timely receipt of certificates of insurance? ___________________________________________________________________ ___________________________________________________________________ Is all 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, attach a copy of the training procedure and documentation method used to ensure adequate 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 when the outside is locked? ___ 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 |