Contractor Insurance Questionnaire

Gather the operational and safety details an insurance broker needs to shop coverage for a contracting business.

Use this template

Name

Nombre

Apellido

Business Name

Estimated Revenue for Next Year

Estimated Payroll for Next Year (W-2 Employees Only)

Business/Mailing Address

Dirección

Ciudad

Estado / Provincia

Código postal

Select All Lines of Coverage You Need Quotes For

How Many W-2 Employees Do You Have?

What's the Reason You're Shopping for Coverage?

How Soon Do You Need a Quote Back?

Detailed Description of Operations

Current Insurance Carrier for Each Line of Coverage (GL, WC, Auto, etc.)

How Long Have You Been With Your Current Carrier?

Have You Had a Claim on Any Policy in the Last 5 Years?

Yes No

Please Explain the Claim(s)

What Kind of Contractor Are You?

Do You Have Any Industry-Specific Certifications? (e.g., ISO, LEED)

Do You Subcontract Any Work Out?

Yes No

What Safety Programs Do You Have in Place?

Safety Training PPE Program Jobsite Inspections Incident Reporting None

What's the Maximum Height Employees or Subcontractors Work at?

Under 10 ft 10-25 ft 25-50 ft Over 50 ft

What Percent of Work Is Subbed Out?

What Is the Cost (Amount Paid) for Subcontracted Work?

Do All Subcontractors Carry Liability Limits Equal or Higher Than Yours?

Yes No

What Kind of Roofing Do You Install? (Metal, Asphalt, Wood Shakes, etc.)

Do You Perform Any Torch-Down Work?

How Do Employees and Materials Get to the Roof? (Scaffolding, Ladders, Lifts, etc.)

Do You Work on Any of the Following?

High-Rise Buildings Historical Buildings Hospitals/Schools Hazardous Materials None

Percent of Commercial vs. Residential Work

Do You Need Coverage for Your Building?

Yes No

What Types of Siding Do You Install?

Do You Install Windows?

Yes No

Do You Perform Roofing Work?

Yes No

Do You Use Ladders, Scaffolding, or Lifts?

Ladders Scaffolding Lifts None

Do You Do Any Work On the Following?

High-Rise Buildings Historical Buildings Hospitals/Schools Hazardous Materials None

What's the Cost of Subcontracted Work? (Dollar Amount)

Do All Subs Sign a Subcontractor Agreement?

Yes No

Detailed Description of Work Performed by Subcontractors

What Year Was the Roof Installed?

What Year Was the HVAC Replaced?

What Year Was the Plumbing Replaced?

What Year Was the Electrical Replaced?

Do You Trim Trees?

Yes No

How Do You Get Up to the Trees? Lifts, Boom Truck, etc.?

List All the VINs, Year, Make, and Models for Your Vehicles

Have You Had Any Safety Violations in the Past 5 Years?

Yes No

If Yes, Please Explain

Certification Statement

Signer Name

Nombre

Apellido

Title/Position

Signature

Sign here

Date Signed

Contractor Insurance Questionnaire

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