SCAFFOLDING SUPPLEMENTAL
CONTRACTORS APPLICATION
Instructions
1. Please complete this application. All questions must be answered.
(If “None” or “Not Applicable” so indicate)
2. If space is insufficient to complete answers, please continue on your firm’s letterhead.
3. This form must be signed and dated by an owner, partner or director/officer of your firm.
_______________________________________________________________________________________________
Application
1.
How long has the Applicant been performing this type of work? ______________
2.
What types of scaffolding equipment does the Insured carry? ( stationery, mobile towers, suspended scaffolds, aerial lifts, pump
jacking or other) ________________________________________________________________________________________
______________________________________________________________________________________________________
3.
Provide the following percentages: Rentals _____% Leases; Long term _____% Short term _____% Permanent sales ____%
Maintenance or repair work ____%
4.
Does the Insured rent or lease equipment unassembled? Yes _____
5.
Does the Insured always install leased or rented equipment? Yes _____ No _____ If no, advise who is responsible for the
installation________________________________________________ Are there contractual arrangements that hold harmless
the Insured if the installation is not performed on behalf of the Named Insured?
6.
Does the Insured require lessees to insure the scaffolding? Yes _____ No _____ If no, does the insured stipulate in their lease
agreement a hold harmless clause? Yes _____ No _____ Does the customer sign this agreement? Yes _____ No _____
(provide copy of rental / lease agreements provided to the Insured customer)
7.
Does the Insured sell equipment that has been previously used? Yes _____ No _____ If yes, provide percentage and details of
the installation ______% performed by whom_______________________________ If the customer performs are they
provided with the following information a) instructions on maintenance and upkeep Yes _____ No _____
b) Detail of the wind limits and other safety information? Yes _____ No _____ c) Is there a contractual agreement with that
holds harmless the Name insured once the customer takes possession of the equipment? Yes _____ No _____ If no, Please
explain________________________________________________________________________________________________
(provide copy of the sale agreement provided to the Insured customer)
8.
Percentage of work performed over two stories in height from grade? Residential _____%
9.
Does the Insured perform site preparation prior to performing work? Yes _____
No _____
Commercial _____%
No _____ If “Yes”, please attach a description.
11. How is the scaffolding protected during work hours (when still in the care custody and control of the Named Insured)?
______________________________________________________________________________________________________
How is the scaffolding protected during off work hours ( when still in the care custody and control of the Named Insured?
______________________________________________________________________________________________________
12. How often is rented/leased equipment inspected? ______________ Repaired?_____________
13. Is there a separate maintenance agreement for sold equipment? Yes _____
agreement for rented/ leased Yes _____ No _____
(provide copy of the sale agreement provided to the Insured customer)
No _____ Is there a separate maintenance
14. How are the insured Inspectors and employees selected, and trained? _____________________________________________
______________________________________________________________________________________________________
Please include the following items when returning this questionnaire:
 Completed AIG Excess Casualty Contractors Application and all requested information
 Seven (7) years minimum hard copy loss runs currently valued within 6 months of the expiration date is required for this class
of business
 All requested contractual agreements and maintenance agreements stated herein.
Signature of Producer
Date
Signature of Applicant
Principal Officer
Date
1