| Name: |
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Contact Name:
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| Web site address : |
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| Address: |
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Suite/Unit: |
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| City:
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State:
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Zip: |
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| Account e-mail address: |
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Phone #: |
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Are you member of a National Association?
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AFSA
NSFA |
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What is the Federal Tax ID number? |
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| Current Policy Expiration Date: |
(mm/dd/yy) |
Deductible: |
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| Limits of Liability Insurance: |
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Current Liability Carrier: |
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| Is the Current Carrier Renewing your coverage? |
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Total Labor Payroll $:
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Total Gross Receipts $:
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Total Cost of Work You Sub Out $:
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| What % of operations are from the installation, servicing or repair of waterbased extinguishing system within the following four categories:
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Category I, Wet-Pipe Systems
% |
Category II, Dry-Pipe System Under Air Pressure
% |
Category III, Pre-Action Systems
% |
Category IV, Deluge Systems
% |
| What % of the operations are from the following:
|
New installation work
% |
Rehab/renovation work
% |
Retrofit work
% |
Service/Repair
% |
| Do you perform any of the following operations: |
- Installation, servicing or repair of chemical-based extinguishing systems, including high expansion foam systems, other than clean agent (halon)?
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- Installation, servicing or repair of clean agent (halon) system > 25% of total operations?
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- Alarm system sales or installation other than the mechanical installation of parts within the sprinkler system (e.g. a water flow detection device)?
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- Manufacturers or distributors of automatic sprinkler heads, valves, gauges, pumps, alarms or detection systems?
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- Sale, installation, servicing or repair of fire extinguishers, ansul-type systems or any other type of packaged or pre-engineered suppression equipment >25% of total operations?
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- Design work for systems not installed by the insured >15% of total operations?
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- Inspection, testing or certification of systems not installed by the insured >15% of total operations?
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| Do you perform design, inspection, testing and/or certification work have a Professional Engineer (P.E.) designation or the National Institute for Certification in Engineering Technologies (NICET) Level III or above? |
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- If No, describe the qualifications of the individual(s) doing this work.
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| Have any professional liability claims been made against the insured due to systems they designed, inspected, tested or certified? |
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- If Yes, please provide the claim details, including date of loss, amount of claim, nature of claim, project description, current status, etc.
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| Company operating as: |
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General Contractor
% |
Prime Contractor
% |
Subcontractor
% |
| Indicate the average percentage of the risk's TOTAL payroll or sales during the past 5 years for the following: |
Percentages based on: (Check One) |
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| COMMERCIAL WORK
% |
INDUSTRIAL WORK
% |
RESIDENTIAL WORK
% |
| Describe your four largest projects over the past years, including values: |
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| List current projects currently underway or planned for the next year, including values: |
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| HABITATIONAL WORK (Please complete in your company does any habitational work) |
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| Do you have any future plans related to work involving apartments, condos, townhouses, tract homes, custom homes or homes of unusual design? |
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| List the states the insured worked in during the last 5 years: |
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| Has your company ever installed or have any future plans involving the installation of EIFS? |
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| Has your company ever been named in claims and/or litigation regarding faulty or defective construction or workmanship, including claims due to subsidence issues or use of EIFS? |
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- If Yes, were you acting as a general or sub-contractor? Was it a habitational or commercial project? Provide detail on claims/litigation and how the issue was corrected.
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| 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? |
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| A. Any current or past involvement with wrap-up/OCIP? |
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| B. Any residential wrap-ups? |
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| Does the risk have a quality control program? |
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Informal or
Documented |
| Does the risk retain job files? |
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- If Yes, how long are they retained?
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| List the types of work subcontracted: |
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- Do you obtain Certificates of Insurance from all subcontractors?
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- Are you named as an additional insured on all subcontractors' policies?
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- Does the risk require all subcontractors to carry primary limits equal to or greater than their own?
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- Do you use written subcontractor agreements containing hold harmless/indemnity agreements in favor of the risk?
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Indicate the types of subcontractor agreements the risk typically signs: |
Standard (AGC, AIA contracts)
Custom
Other |
| Additional Questions |
| Does the insured have a New Hire Orientation Program with pre-physicals, drug screening, etc.? |
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| Are safety meetings held with attendance by mgrs. And employees with attendance records kept? |
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| If subs are hired, are all contracts reviewed by legal counsel or the insurance agent? |
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| Is there a Diary System in place to track expiration dates of certificates of insurance? |
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| What percentage of your work id CPVC-New
% |
Retro or Repair
% |
| Are all fitters trained on the various cure times for different size pipes? |
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| How long do you let a "cut-in" cure for pipes |
1 1/4"
, 1 1/2"
and 2"
? |
| Is the cure time adjusted for temperature?
|
Humidity ?
& Angle cut of pipe?
|
| Prior year number of employees |
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| Current year number of employees |
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Name
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