ROOF ONTRATORS LIABILITY QUESTIONNAIRE INSTRUTIONS A. Please answer all the questions and return to Fenn & Fenn Insurance Practice Inc at the address under D below. If you have questions please contact us. B. If a question is not applicable, state N/A, please leave no blank areas. If more space is required to answer any question, please attach an exhibit stating the question number.. On completion please mail, e-mail or fax this information to : Fenn & Fenn Insurance Practice Inc, 70 Main Street South Newmarket, Ontario L3Y 3Y6 Telephone: 905 836 6066 Facsimile: 905 836 9814 hello@fenninsurance.com ompletion of this questionnaire is not binding on the applicant or the Insurer. I. APPLIANT: 1. Name of Applicant: 2. Address of Applicant: No. Street ity Province Postal ode 3. Main ontact Name: Telephone: Information: Title: Fax: E-Mail: 4. Business Information: orporation: Partnership: Individual: Other (Specify): 5. Years in business: Website: 1
6. Name and address of domestic (Dom.) and foreign (For.) subsidiaries, if any: Name Address Dom. For. Name Address Dom. For. II. BUSINESS OPERATIONS: 1. Description of all business operations conducted by the Applicant by type: 2. Employees/ anada$$ U.S.A.$$ Other$$ Payroll No. of employees: Annual Payroll: 3. Actual Gross revenue: A) Roof ontracting: $ and B) Other operations: $ Describe: ) Estimated percentage of A & B covered by Project Specific Wrap Up Liability Insurance: % (Wrap Up is a general liability policy supplied by Owners or General ontractors that insures the Owner, ontractor and all subcontractors on a project specific primary basis. It is commonly seen on larger construction projects). 4. Percentage Split of roof contracting gross revenue, Industrial/ ommercial/ Institutional (II) vs. Residential: 2
5. Estimated Annual roof contracting gross revenue: Rate ategory: Open Flame Applications Work Type NEW $$ RE-ROOF $$ Built up roofing/hot Asphalt: Modified Bitumen (Torch Applied): Other Open Flame: Describe: Rate ategory: Other Roofing Applications (No Open Flame) Work Type NEW $$ RE-ROOF $$ Built Up roofing (old) Modified Bitumen (No Torch): EPDM: TPO: Liquid Applied: PV: Sprayed Foam: Metal: Shakes/Shingles/Tiles/ Slate: Rate ategory: Other Work For green roof, please complete the attached addendum Work Type New $$ Other Work (Describe): Renovation/ Re-roof $$ 6. Amount and type of work you subcontract to others: Specify by type of work: Annual ost: a) $ b) $ c) $ Do you ask sub-contractors to furnish proof of liability insurance? YES NO If yes, what minimum limit of liability do you require: $ 3
III. ONTRATUAL LIABILITY 1. If D or other Standard recommended forms are used please state below. D (other) Standard ontract Reference Numbers used: 2. If other than D used, attach wording examples (the indemnification and insurance sections) of typical types of contracts, purchase orders or other written agreements where you assume liability. Other ontract Indemnification & Insurance Wordings Attached: YES NO IV. PRODUTS LIABILITY 1. Do you manufacture, sell, handle or distribute any products other than roofing products: YES NO Describe: V. RISK MANAGEMENT & LOSS PREVENTION 1. Does applicant have a safety programme including orientation & training for new employees? YES NO 2. Does the applicant provide ongoing training for all employees? YES NO 3. Does applicant follow RA pre-apprenticeship training for roofers? YES NO 4. Describe fire prevention measures taken to prevent fires at job sites including number and type of fire extinguishers: 5. Are portable smoke/heat detectors used? YES NO 6. Are spray on fire retardants used? YES NO 7. Do you prohibit smoking on jobsites? YES NO 8. Describe measures taken to prevent water damage (including hoarding and other details): 9. Provide details of propane tank storage, maintenance and safe handling: 10. Are only properly trained personnel engaged in handling & operation of propane tanks: YES NO If NO, please explain: 11. Describe precautions to store equipment & hazardous materials at jobsites after working hours: 12. Describe other safety measures used to prevent injuries to workers, third parties and damage to property: 4
VI. RISK MANAGEMENT & LOSS PREVENTION 1. Are torch system manufacturers recommendations followed? YES NO 2. Is all hot work, including torch work supervised? YES NO 3. Do only trained personnel use torches? YES NO 4. Are roofing material manufacturers specifications followed? YES NO 5. Are hot trowels used to finish work details? YES NO 6. Are torch stands used? YES NO 7. Is each torch equipped with a UL listed regulator? YES NO 8. Do you torch on wooden decks? YES NO 9. Is all pressure equipment fitted with operating pressure gauges? YES NO 10. Are hot air welders or electric heat seaming devices used? YES NO 10. Does the applicant ensure that all work is inspected at completion of (1) job and (2) day. YES NO 11. Please attach manufacturers torch safety or other roofing system training certificates. YES NO 12. Are all employees covered by WSIB? YES NO Please confirm the number of Lost Time Injuries your company has sustained in the past three years? 13. Other risk management and loss prevention comments that you feel may be useful: 14. Please attach an electronic picture of your business premises including the yard 5
VII. LOSS EXPERIENE List all third party liability claims/actions made against you within the last five (5) years, whether paid by your insurer or not: Description of occurrence: Date of Deductible laim Amount Paid or Expenses Paid or Occurrence: Open Reserved (P/R): Reserved (P/R): (dd/mm/yy) (O) or losed $ O $ P R $ P R Attach additional page if further space required. Please provide a detailed description of any incident. 6
VIII. OVERAGE REQUIREMENTS 1. ommercial General Liability: urrent Limit of Insurance: $ 2. Umbrella & Excess Liability: urrent Limit of Insurance: $ 3. urrent ommercial General Liability Deductible: $ IX. HISTORY OF GENERAL LIABILITY & UMBRELLA LIABILITY POLIIES: overage History Insurer Policy Term Limit in $$ Premium $$ Dd/mm/yy to Dd/mm/yy (Expiring Policy) General Liability (urrent Term): to Umbrella Liability (urrent Term) (Prior 2 Years) General Liability: to to Umbrella Liability to Do these policies insure all corporations and subsidiaries listed in Item I? YES NO If no, explain: Has any insurer ever refused or cancelled any insurance? YES NO If YES, provide details as to why: Are you aware of any situation that might give rise to a claim? YES NO If yes explain: 7
STATEMENTS/DELARATIONS THE APPLIANT WARRANTS IT HAS AUTHORITY TO SUPPLY THE INFORMATION PRESENTED HEREIN AND THAT ALL STATEMENTS ARE TRUE AND ORRET TO THE BEST OF ITS KNOWLEDGE AND THAT NO MATERIAL FATS HAVE BEEN SUPPRESSED OR MISSTATED. THIS QUESTIONNAIRE IS FOR THE PURPOSE OF PREPARING QUOTATIONS FOR OVERAGE UNDER THE ROOF ONTRATOR S LIABILITY INSURANE PROGRAMME. IT IN NO WAY ONFIRMS OVERAGE TO BE IN EFFET OR BOUND WITH AN INSURER. I have read and accept the Statements/Declarations hereon: Name: Title: ompany: Date: Signature: 8
GREEN ROOFING ADDENDUM Rate ategory Green Roofing (including vegetated, photovoltaic &/or wind turbine installations where risk of work rests with your company.) Work Type NEW$$ Re-ROOF$$ Vegetated Roofing Photovoltaic Wind turbine ombination of above 9