Contractor Audit/Survey
Survey Date:Completed by:
Name on Policy:Policy #:
Address:City:
State:Zip:
Phone:Email Address:
Liability
Describe type of work performed:
In more than one trade, describe primary and secondary functions and % of work each constitutes.
Primary%
Secondary%
Length of Time in BusinessYears
Total Years Experience in Trade(s)Years
Percentage of Commercial work performed%
Percentage of Residential work performed%
Describe total experience if in business fewer than three years.
Is this the insureds principal employment?YesNo
If no, what is your principal employment?
Annual Receipts$
Annual Employee Payroll$
Annual Salary for owners$(Subject to a minimum of $20,000 each)
Radius of Operationsmiles
Operations outside of New York State?YesNo
If Yes, Please describe:
Number of Owners:
Number of Full Time Employees:
Number of Part Time Employees:
Do you lease employees from a leasing agency?YesNo
If yes, how many employees do you lease?
Is any work subcontracted?YesNo
If yes, list subcontractors used:
Amount paid to subcontractors in the past twelve months$
Cerificates on FileYesNo
Do you rent or lease equipment to others?YesNo
If yes, describe type of equipment :
Are you or your subcontractors involved in any of the following:
DemolitionYesNoRoofingYesNo
Pesticides/asbestosYesNoExcavationYesNo
Exterior work over three storiesYesNoBlasting/explosivesYesNo
Operations w/flammables or chemicalsYesNoGeneral ContractingYesNo
Snow PlowingYesNoTree CareYesNo
Spray PaintingYesNoLawn ServiceYesNo
1. Are you involved in the repair, installation or servicing of the following?
BoilersYesNoFire/Burglar AlarmsYesNo
Sprinkler SystemsYesNoComputersYesNo
If any of the above are yes, please describe:
2. Do you manufacture and/or sell any products that are not installed?YesNo
If yes, please describe:
3. Are there any underground storage tanks utilized, including but no limiting locations such as shop, residence or job site?YesNo
If yes, please describe:
4.Has any coverage been declined, cancelled or non-renewed in the past three years?YesNo
If yes, please describe:
5. Have there been any losses in the past three years?YesNo
If yes, please describe:
Briefly describe the three largest jobs you have had in the last eighteen months including the appropiate dollar amount:
Job #1$
Job #2$
Job #3$
Additional Comments:
IMPORTANT NOTICE TO POLICYHOLDER
"Any peson 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, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation."
As part of our underwriting procedure, a routine inquiry may be made which will provide applicable information concerning character, general reputation, personal characteristics and mode of living.  A Consumer Report may be requested by the insurer to which this application is assigned. Subsequent consumer reports may be requested in connection with an update, or renewal, or extension othe insurance to which this application is made.  The applicant, upon written request, will be informed whetheror not a consumer report was requested - and if such was requested, informed of the name and address of the consumer reporting agency that furnished the report.  The person completing this survey hereby affirms that the statements and representations made herein ae true to the best of his/her knowledge.