NETWORK E&S INSURANCE BROKERS
ROOFERS GENERAL LIABILITY
SUPPLEMENTAL QUESTIONNAIRE
Applicant Instructions:
Answer all questions. If the answer to any question is NONE, please state NONE.
Questionnaire must be signed and dated by owner, partner or officer.
PLEASE CAREFULLY READ THE STATEMENTS AT THE END OF THIS QUESTIONNAIRE.
THE TERM “WILL YOU” IN A QUESTION MEANS UNTIL THE EXPIRATION DATE OF THE POLICY.
1. Applicant: ________________________________________________________________________________________
Business Address: _________________________________________________________________________________
2. Please describe your roofing operations by the type of work performed. Indicate the percentage of each type of work.
Type Commercial Residential
(Includes apartment work)
New Construction _____% _____%
Repair/Patching _____% _____%
Replacement _____% _____%
Asphalt Shingle _____% _____%
Tile _____% _____%
Fiberglass _____% _____%
Flat Roofs _____% _____%
Hot Tar _____% _____%
Metal _____% _____%
Pitch Roofs _____% _____%
Other – describe: __________________________________________________________________________________
3. (a) Any hot tar work? Yes No
If “Yes”, what percentage: _____%
(b) Any Torch Down work: Yes No
If “Yes”, what percentage: _____%
(c) Does any Torch Down work involve combustible decks or walls?
If “Yes”, please explain: ______________________________________________________________________________
_________________________________________________________________________________________________
4. Describe the safety precautions put in place if hot tar, torch down or other hot processes are used:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
5. Any sheet metal work other than in connection with roofing operations? Yes No
If “Yes”, please explain: ______________________________________________________________________________
_________________________________________________________________________________________________
6. Any Sprayed-on roofing? Yes No
If “Yes”, what type of material: ________________________________________________________________________
_________________________________________________________________________________________________
RQ-001 (10/07) 1
7. Does applicant rent a crane? Yes No
If “Yes:
a. With or without operator?_______________
b. How many times a year on average?_______________
c. What is the average size of the crane? ________________
8. A. Describe the procedure utilized by applicant to determine the possibility of the onset of inclement weather:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
B. Describe the procedure utilized by applicant to protect an open roof when leaving a job site for an extended period of
time:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
9. Describe any other operations or work performed other than roofing:
a. Water proofing: ______________________________________________________________________________
b. Rain gutters: ______________________________________________________________________________
c. Asbestos removal: ____________________________________________________________________________
d. Siding: _____________________________________________________________________________________
e. Carpentry: __________________________________________________________________________________
f. Insulation:___________________________________________________________________________________
10. Does applicant have a documented and enforced fall protection program? Yes No
a. Please describe: _____________________________________________________________________________
b. Does the risk’s fall protection program meet minimum OSHA requirements? Yes No
11. Do you draw plans, designs or specifications? Yes No
If “Yes”, please explain: __________________________________________________________________________
______________________________________________________________________________________________
12. Are all jobs inspected by a foreman or the contractor at completion before leaving the job site? Yes No
Signature of Applicant: __________________________________________
Title (Owner, Officer, Partner) ____________________________________
Date: _______________
SIGNING THIS QUESTIONNAIRE DOES NOT BIND THE APPLICANT OR THE INSURER OR THE
UNDERWRITING MANAGER TO PROVIDE THE INSURANCE.
RQ-001 (10/07) 2