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Contractor Supplemental Questionnaire Form
To be used in conjunction with the ACORD 125 and 126 applications
AGENT
Agency Code:  Date: 
Agency Name
Agency Email
APPLICANT INFORMATION
Name (Include DBA)  
Tax ID# (FEIN/SSN)  Years In Business 
City/State/Zip      Owner Experience
DESCRIPTION OF OPERATIONS
Please provide a brief narrative explaining the scope of work.

Avoid using vague terms (ie: Remodeler, General Contractor, etc)
Please Mark Limits Requested: 100 300 500 1000 1000/2000
What are the duties of the Owner(s)?
Please indicate the percentage of operations in the respective field
Residential %     Multi-Family %     Tract Houses %    
Commercial %     Institutional %     Remodeling %    
Operations Questions
Are all operations within the state of Texas? Yes No
If not, what state(s) are operations occuring within?
Does applicant subscribe to Workers Compensation? Yes No
Is the applicant registered with the TRCC or have any Trade Licensing? Yes No
Explain TRCC or Trade Licensing
Does the applicant carry any type of Professional Coverage? Yes No
If so, what type of Professional Coverage?
Work Performed
The following questions pertain to the applicant's employees and any uninsured subcontractors
Roofing, plumbing and EIFS are excluded from the Dallas National GL Policy. Is any of this type of work being performed by the employees or uninsured subcontractors? Yes No
Is the applicant involved in utility construction? Yes No
If so, are connections made by the applicants company? Yes No
Does applicant use a lateral boring machine? Yes No
Do any operations involve demolition of complete structures? Yes No
Is there any work above 3 stories? Yes No
Is there any equipment (such as cranes) rented by applicant? Yes No
Are there any underground parking lots or coffer dams constructed by applicant? Yes No
Is installation of security equipment or alarm systems part of the applicants work? Yes No
Is any work related to highway or bridge construction? Yes No
Does applicant position or set-up barricades? Yes No
Is there any Model Home exposure? Yes No
Explain any YES answer in the space provided below
FINANCIAL INFORMATION
Please complete the following sections as completely and accurately as possible
   Gross Receipts
Anticipated for next 12 months    
Current Year    
Previous Year    
 
   Payroll
Payroll and uninsured sub cost must be listed on the schedule below
Number of Employees (FT/PT)     
Employee Payroll (Excluding Owner)   $
Labor Costs for UNINSURED Subcontractors   $
 
Phase Of Work
Employee Payroll
  
UNINSURED Sub Contractor Cost
Architectural Work  
Carpentry (Framing/Cornice)  
Carpentry (Interior)  
Concrete Construction  
Debris Removal  
Demolition  
Driveway Paving/Sidewalk  
Drywall  
Electrical  
Engineering  
Excavation  
Executive Supervisor  
Fence Erection  
Flooring (Carpet)  
Grading Of Land  
HVAC  
Insulation  
Janitorial  
Landscaping  
Masonry  
Metal Erection (Dwellings)  
Metal Erection (Non-Structural)  
Metal Stud Construction  
Painting (Exterior)  
Painting (Interior)  
Plastering/Stucco (No/EIFS)  
Plumbing  
Refrigeration  
Roofing  
Sheet Metal (Outside)  
Swimming Pool Construction (Above)  
Swimming Pool Construction (Below)  
Swimming Pool Service (No Repairs)  
Tile/Stone/Terrazzo (Interior)  
Welding  
Other  
Other  
   Insured Subcontractors
Do subcontractors carry their own GL policies with equal or greater limits? Yes No
If so, do they name the subject as an additional insured with a waiver of subrogation? Yes No
Do the subcontractor subscribe to Workers Compensation Insurance? Yes No
Total INSURED Sub Cost (Including materials) $
   Additional Insured Interests
Will the applicant need to name any entity as an additional insured? Yes No
Will these interests need a waiver of subrogation as well? Yes No
How many entities are expected to be named?
 
CC Yourself the submitted information?
 
    
 
CONTRACTOR'S SUPPLEMENT

If you would prefer, you may use the PDF document on the link shown, and complete and email manually to the Turner offices. Click here for the Contractor's Supplement application  
If you do not yet have Adobe installed on your computer then please click here here to download a free version.
 
 
  Turner General Agency, Inc.
Phone: (888) 443.7932 ~ (972) 290.7200		 Fax: (972) 203.8206 Email: Brett Turner at 
brett@turnercompanies.com  		 

 


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