General Liability Inspection

Please enter your Policy Number

Operations

Please enter your Annual Gross Receipts

How many field-working W-2 employees do you currently employ (do not include owners, sales, or clerical)?

What is your estimated field-working employee payroll for the 12 month GL policy period?

Do you perform any new construction work on Condo’s, Townhomes, Apartments, or any other multi-unit residential projects?

Yes

Do you ever use casual labor/day labor that are not your W-2 employees?

Yes

Subcontractors

As the named insured please confirm the following related to subcontractors hired by you or your company.

All subcontractors are required to provide a written indemnity agreement holding you (the insured) harmless for all liabilities, including costs of defense, arising out of the work of the independent contractor.

Yes

All subcontractors are required to provide certificates of insurance and additional insured endorsements naming you (the insured) as an additional insured on the independent contractor’s commercial general liability insurance.

Yes

All subcontractors are required to maintain general liability insurance with minimum limits not lower than the limits of the applicants general liability policy, that shall remain in full force, and shall not be more restrictive than the coverage provided under the applicants general liability policy.

Yes

All subcontractors are required to maintain general liability insurance with the same coverage provided to the additional insured as the named insured.

Yes

All subcontractors are required to sign a written contract with the applicant stating the nature of the subcontracted work.

Yes

All subcontractors are required to hold a valid license in their respective trade.

Yes

All subcontractors are required to pull permits from local building departments as required by code.

Yes

Work Restrictions & Limitations

The insured certifies that under no circumstances, during the course of their work, they never perform any work:

in excess of three (3) stories or thirty-six (36) feet in height.
in excess of six (6) feet in depth.
on gradients or slopes in excess of fifteen (15) degrees.
on retaining walls in excess of six (6) feet in height.
or installation on wood, coal, oil, and/or waste burning stoves.
involving mold, asbestos, and/or environmental remediation (requiring a license).
involving pesticides and/or herbicides (requiring a license).
involving of fire extinguishing systems.
on railroads, airports, utility companies, municipalities, or traffic lights.
on petroleum plants or chemical facilities.
on elevators, escalators, or ski lifts.
related to foundation retrofitting or foundation repair and/or stabilization
on swimming pools including installation and/or service and repair.
involving fiber optics.
involving tunneling operations.

Tract Home Restrictions

The insured certifies that:

The insured never performs work on any housing project or development that includes the construction of fifteen (15) or more single-family homes, whether attached or detached, in any or all phases of the project or development, regardless of the number of developers?
The insured is not a developer, general contractor, sub-contractor, independent contractor, or any other party involved in the new construction of tract housing.

The undersigned confirms that they are an authorized representative of the insured; represents that they have provided accurate answers to all questions on this inspection; represents that the answers are true, correct and complete to the best of his/her knowledge; and further authorizes electronic communications from Coverage Validator and related entities.

Your First Name

Your Last Name

FRAUD WARNING

Any person 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 subjects such person to criminal and civil penalties. The undersigned is an authorized representative of the applicant and represents that reasonable enquiry has been made to obtain the answers to questions on this application. He/she represents that the answers are true, correct and complete to the best of his/her knowledge.