Wireless Questionnaire

Legal Name: ______

List all names/entities that you operate under: ______

______

Address:

Telephone Number: Fax Number:

Cell Number: FEIN#:______

Main Contact: ______E-Mail Address:

Website Address:______

Type of Organization:

Individual Partnership / Limited Liability Corp. / Subchapter S
Corporation / Partnership / Other: ______
Joint Venture / ESOP / ______

Operates as: General Contractor Subcontractor

YES NO

Are you a member of NATE?

Are you a member of your state Wireless Association?

Are you a member of another association?

If yes, please list ______

Are Job Files retained? If yes, how long? ______

Date business started:______Years of Experience in this type of work ___

State of Incorporation:

Number of employees: ______

Ownership:

Subsidiary of another company? Yes No

Names of Owners and Percentage of Ownership:

______

Are officers Excluded from Works Compensation? Yes No

Payroll:

Gross payroll for the work/services provided:

Percentage / Payroll
(direct employees) / Subcontracted Cost
Antenna Installation
Antenna Service/Repair
Landscaping Installation
Landscaping Maintenance
Tower Erection
Tower Maintenance/Repair
Foundations
Electrical Installation
Lighting Install/Repair
Painting
Concrete (slabs)
Grading
Fencing
Shelter/Trunk Box Install
Equipment Installation In Shelter/Trunk box
Tower Modifications
Battery Delivery/installation
Gin Pole Work
Generator refueling
Other (describe)
Totals: / 100 %

Estimated Annual Revenues: ______

Crane exposures:

Yes No

Are cranes or hoists used in the course of construction?

Are cranes or lifting devices leased?

Contractor’s equipment policy cover leased equipment?

Number owned: ______

Total equipment rental expense that you operate: ______

Equipment leased or rented to others:

Without Operator:

Percentage of Work done above 100 feet: ______

Percentage of work done above 300 feet: ______

Work done within 50 feet of railroad right of way: $ (Revenues)

States in Which Principally Operate:

(Show approximate split of payrolls by state)

Alabama / ______/ Montana / ______
Alaska / ______/ Nebraska / ______
Arizona / ______/ Nevada / ______
Arkansas / ______/ New Hampshire / ______
California / ______/ New Jersey / ______
Colorado / ______/ New Mexico / ______
Connecticut / ______/ New York / ______
Delaware / ______/ North Carolina / ______
District of Columbia / ______/ North Dakota / ______
Florida / ______/ Ohio / ______
Georgia / ______/ Oklahoma / ______
Hawaii / ______/ Oregon / ______
Idaho / ______/ Pennsylvania / ______
Illinois / ______/ Rhode Island / ______
Indiana / ______/ South Carolina / ______
Iowa / ______/ South Dakota / ______
Kansas / ______/ Tennessee / ______
Kentucky / ______/ Texas / ______
Louisiana / ______/ Utah / ______
Maine / ______/ Vermont / ______
Maryland / ______/ Virginia / ______
Massachusetts / ______/ Washington / ______
Michigan / ______/ West Virginia / ______
Minnesota / ______/ Wisconsin / ______
Mississippi / ______/ Wyoming / ______
Missouri / ______/ TOTAL: ______

Professional Liability:

YES NO

Architects and engineers exposure: $

Design-build? Revenues: $______

Construction Management?

Contingent Professional Exposure

Subcontractor exposure:

Percentage of work sublet: ______Total Cost of work sublet:$ _____

Description of work performed by subs: ___

______

Yes No

Use standard subcontract – please attach a copy

Require waiver of subrogation

Require naming as insured

Insurance considered primary

Obtain valid certificate, as a requirement to make payment

Hold Harmless Agreement

Minimum limit of coverage that you require of your subcontractors:

¬ General Liability $ ______

¬ Auto Liability $ ______

¬ Employers Liability $ ______

Who provides specifications for work to be performed? ______

Plan reviewed and approved by Professional Engineer?

Yes No

¬ Applicant

¬ Tower Owner

¬ Customer

Vehicle Analysis:

YES NO

Do owners carry a personal auto policy?

Do you pull MVR’s on drivers? If yes, how often: ______

How many violations are permitted? ______

Do vehicles have permanently installed GPS?

Do you rent vehicles?

Scheduled vehicle maintenance program?

Are vehicles taken home at night?

Is personal use of vehicles permitted?

Do you have a driver acceptance matrix?

Do you have a Cell phone policy in place?

DOT Number: ______

Loss Prevention and Safety:

*please provide resume of key individuals involved in safety

Safety personnel profile: Number full time Number part time

Safety Management:

Yes No Yes No

Pre-employment checks / Training/orientation
Pre-employment physicals / programs
Pre-employment drug tests / Fall Safety
Current employee drug test / Tower Rescue
Driver MVR’s screened / OSHA 10 or 30
Employee handbook / Driver Safety
Pre-job safety assessment / Post accident drug screening
Comtrain Certified

How often do you have safety meetings? ______

safety Incentive /disincentive Programs In Place:

Property:

Do you have an office building or work from home? ______

If you have an office building please provide: Age, Type of Construction, Protection in place (sprinkler, fire/burglary alarm)

______

Do you rent equipment over $ 50,000? ______

Do you maintain or service generators? ______

Do you replace batteries on cell tower sites? ______

Do you store materials of others at your location(s)? ______

If Yes, what is the average value? ______

Checklist:

Vehicle List & trailers (Year, Make, Model, VIN) with a list of all drivers (Full name, Date of Birth, License number & state)

List of Equipment (anritsus, winches, skid steer, etc) with the descriptions and values

Resume of at least one key personnel/owner and safety manager

Current certificate of Insurance

Current insurance policies

loss runs (3-5 years on all policies is perferred)

Experience Mod worksheet if available

Do you have any agreements that we can review?

copy of drug free certificate (if applicable)

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