Risk Profile Form "*" indicates required fields Step 1 of 20 - Agent Information 5% Agent InformationAgency Name*Agent Name*Phone Number*Email Address*Company InformationLegal Company Name*DBA*Insured Contact (Last, first, middle initial)*FEIN #*Address*Address Line 2City*State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip Code*Fax NumberPrimary phone number*Other phone numberEmail address*Do you have a website?* Yes No Website*Loss Control Contact*Phone Number*Loss Control Contact Email* Company Information ContinuedDescription of Operations*Description of specific operations (Note: Cell tower contractor is not acceptable)Type of Organization* LLC Inc. LP JV Sole Proprietor Date organization started*Years of experience in field*State of incorporation*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingHas the ownership of company changed in the past 5 years?* Yes No If yes, provide details:*Number of Full-time employees :*Number of Part-time employees:*Is this a subsidiary of another company?* Yes No Who are your 5 main customers?*(Ex: AT&T, Verizon, Crown Castle, etc.)Do you do any work for Crown Castle?* Yes No Do you work on Crown Castle Property for others?* Yes No Does your company conduct work for the government or any city municipality?* Yes No Please list all Owners/OfficersList all Owners*NameTitleDOBOwnership % Add RemoveAre owners/officers included on the Workers Compensation policy?* Yes No Are all owners active in daily operations?* Yes No If no, explain:* Payroll/Sub Cost EstimatesProvide the gross annual payroll and sub costs for the work/services provided.L&A Installation, Service or Repair, Electrical (Groundwork), Rooftop Work, Lighting Install/Repair, Generators- install or service, Small Cell work, DASPayrolls (Direct Employees)Subcontracted CostTower Modification (structural), Tower ErectionPayrolls (Direct Employees)Subcontracted CostTower Modification (Non Structural), New LandscapePayrolls (Direct Employees)Subcontracted CostConcrete-FlatworkPayrolls (Direct Employees)Subcontracted CostCaisson, Pad and PierPayrolls (Direct Employees)Subcontracted CostLandscape MaintenancePayrolls (Direct Employees)Subcontracted CostGrading New Construction/Site Prep, ExcavationPayrolls (Direct Employees)Subcontracted CostGrading (Existing Site)Payrolls (Direct Employees)Subcontracted CostPainting, Tower Painting (Exterior Structures - Tower or Shelter)Payrolls (Direct Employees)Subcontracted CostConduit- (Separate from drilling/ boring)Payrolls (Direct Employees)Subcontracted CostDrilling or BoringPayrolls (Direct Employees)Subcontracted CostEngineers-Licensed (Office Only-No Jobsite)Payrolls (Direct Employees)Subcontracted CostEngineers - Licensed (Consulting - Job Site Work)Payrolls (Direct Employees)Subcontracted CostExecutive Supervisor (No Jobsite)Payrolls (Direct Employees)Subcontracted CostOutside SalesPayrolls (Direct Employees)Subcontracted CostFence ErectionPayrolls (Direct Employees)Subcontracted CostCable Pulling- Separate from Drilling/ BoringPayrolls (Direct Employees)Subcontracted CostContractors Permanent Yard & Warehouse (Permanent Yard - Storage of materials at a permanent site away from the jobsite. Storage facilities operated at a jobsite are assigned to the governing class.Payrolls (Direct Employees)Subcontracted CostHVACPayrolls (Direct Employees)Subcontracted CostClerical- Office EmployeesPayrolls (Direct Employees)Subcontracted CostOtherPayrolls (Direct Employees)Subcontracted CostSubcontracted percentage based on PayrollTotals for PayrollTotals for Subcontracted Costs** Accurate payrolls must be kept. Payrolls CANNOT be kept by percentages. Payrolls on ACORD Applications must match totals above.** Upcoming year estimated annual revenues*Subcontracted percentage based on Revenue5 year revenue historyYearRevenueTotal Payroll for YearYearRevenueTotal Payroll for YearYearRevenueTotal Payroll for YearYearRevenueTotal Payroll for YearYearRevenueTotal Payroll for Year Professional Liability ExposureDo you employ licensed architects and/or engineers?* Yes No Do you design towers?* Yes No Do engineers stamp plans?* Yes No Do engineers map systems/ paths only?* Yes No Exposure AnalysisWhat percentage of work is at heights?*Does your company work on broadcast towers over 1000 FT?* Yes No Are you working on broadcast equipment, cell equipment or both on broadcast towers?* Yes No Total revenue of work completed within 50ft. of railroad right of way?*Do you maintain/service generators or replace batteries that would require Pollution coverage?* Yes No Are there any operations outside the normal operations of telecommunications?* Yes No If Yes, provide details*Does your company own any towers?* Yes No States in which you principally operateAny work in NY?* Yes No Any work in IL?* Yes No What percentage will be in Cook County and/or Dupage County?*Any work in TX?* Yes No What % will be in Willacy, Cameron and/or Hidalogo Counties?*Are you working outside of the continental US?* Yes No List all Countries/US territories*Do you have Foreign Travel Coverage in force? (WC, Auto, GL, etc.)* Yes No **Please provide identification unemployment number for: NJ, UT, RI, MN, ME & CO* Type N/A in the box if not applicable. This is a requirement for the above states. Show approximate percentage of work by state - Total must be 100%AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaine **MarylandMassachusettsMichiganMinnesota **MississippiMissouriMontanaNebraskaNevadaNew HampshireNew Jersey **New MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode Island **South CarolinaSouth DakotaTennesseeTexasUtah **VermontVirginiaWashingtonWest VirginiaWisconsinWyomingTotal Fiber/ Utility/ Drilling/ Boring ExposurePlease Select Not Applicable Type of machinery used*How deep are you drilling/ boring in FT?*How many years of experience does the operator have? (Months or Years)*Percentage of revenue generated from this operation*Are you pulling cables and laying conduit?* Yes No Do you use an outside company to mark utilities?* Yes No Are you drilling/boring?* Yes No Do you have an in house procedure for marking utilities?* Yes No Are you boring under railroads?* Yes No Are you boring under roads?* Yes No If yes, please explain* Subcontractor ExposurePlease Select Not Applicable What is the total percentage and cost of annual work subcontracted (material & labor)?*Describe the specific work performed by your subs. Note: Cell tower services is not acceptable*Please check if any apply to your subcontractor agreement*Do you complete field safety and health audits? Standard indemnity/hold harmless agreement Subcontractor’s insurance considered primary and non-contributory Waiver of subrogation Valid certificate of insurance as a requirement for payment Field safety and health audits N/A Minimum limit of coverage that you require of your subcontractorsGeneral Liability occurrence limit($1 million required)Auto Liability occurrence limit($1 million required)Employers Liability occurrence limit($1 million required)Do your employees have direct supervision over sub’s employees?* Yes No Do you use any independent contractors?* Yes No If yes, for what purpose?*Do you pay them via 1099?* Yes No Do you have an independent contractor agreement with them?* Yes No Vehicle/Driver AnalysisPlease Select Not Applicable Do the owners have a personal auto policy? Yes No Do you, not your insurance agent, pull MVR's on all drivers? Yes No How often?How many violation are permitted on driver's MVR per your guidelines?Do your vehicles have GPS units? Yes No Are realtime telematic features utilized? Yes No Dash Cameras in vehicles Yes No What are the features?Does it capture higher risk driving behavior (speeding, harsh braking, rapid acceleration, etc)? Yes No Who receives this information?How is this information used?Does telematics provider offer driver scorecards to evaluate overall driving behavior? Yes No Does employees that consistently show risky driving behavior receive coaching, warnings, write ups, disciplinary steps, pulled from driving duties or even termination?Telematics service providerHow often are videos reviewedHow long are videos kept?Do you rent/ lease vehicles? Yes No Do you have any rented vehicles over the value of $50,000? Yes No Are the vehicles owned or leased? Owned Leased Do you have a scheduled vehicle maintenance program? Yes No Do you have a scheduled vehicle with a salvaged title? Yes No Do you have in-house mechanics or use a 3rd party mechanic? Yes No Do employees use their personal vehicles for business purposes? Yes No Do you require all employees using their personal vehicles to carry minimum of $300,000 liability limits? Yes No Do you obtain COIs from employees to verify personal limits? Yes No Do you have a vehicle/auto safety program? Yes No Please check any you have included in your auto safety program: Alcohol/Drug Use Seat Belt Use Distracted Driving Are employees allowed to use business vehicles for personal use? Yes No If yes, please provide details*Are you required to carry cargo coverages? Yes No Do you have a DOT number? Yes No DOT # and State*Do you maintain seperate CDL files on all drivers including current MVR and medical record? Yes No Classroom training your company requiresPlease check the training you require Annual Competent Climber/Rescuer Authorized Climber Authorized Rescuer Basic Rigging Competent Climber Competent Rigging for Gin Pole/Tower Erection Crane Spotter & Signal Person First Aid/CPR/BBP Hazard Assessment for the Telecommunications Industry Hazard Communications Helicopter External Sling Load Operations OSHA 10 OSHA 30 RF/ EME Awareness Training SPRAT - specialized rope Tower inspection Train the Trainer Certification Unmanned Aerial Systems (UAS/DRONE) Flight Training for Tower Crews Do any of your employees have NWSA certifications? Yes No Please check NWSA Certifications employees have Practical examiner Foreman TTTI TTTII L&A Specialty Percentage of your employees that have NWSA Certifications*Do you require a competent person onsite at all times? Yes No Additional Certifications you requireDo you endeavor to hire employees with 2 years or more experience? Yes No Specialized WorkGin Pole Yes No Basic Mounted Hoist Yes No Tower Safety Information** All ACORD Applications must be completed for all locations. All conditions must be included by COPE (Construction, Occupancy, Protection, Exposures) Information.Do you employ tower climbers? Yes No Tower Height % Please enter the % for each selection0 up to 300’*301-500'*> 500’UP TO 1,000’*> 1000’*What is the maximum height in FT your company works?*Percentage of Work*What is the average height in FT your company works?*Percentage of Work*Any night climbs?* Yes No What %Tower Climber Safety Equipment - Select if Provided* Climbing Harness Eye Protection When Required Foot Protection – Steel toed boots/ rigid sole RF Hand Protection – Gloves Head Protection – Climbing helmet N/A RF Detector Does your company allow employees to use their own safety equipment?* Yes No Please describe*Do you provide fall protection equipment to your employees?* Yes No How often is equipment inspected and by whom?Tower Climber Safety Equipment - Select if Provided Fall protection equipment & helmets removed from use if involved in a fall event Lock out/Tag out protocol for working on/near high voltage lines & electrical hazards First Aid & Emergency rescue procedures developed & documented for each site Appropriate warning & danger signs posted and maintained at the jobsite Pre-Climb Inspection Guidelines - Select if applicable to your company* Check for loose or missing hardware Check for climbing obstructions Check for hazards such as birds nest; bees/wasp nests; ice on tower Guy towers – any sign of decay on anchor rods; proper installation of turnbuckles; proper # of threads; proper tension of the guy wire N/A Tower Climber Safety Controls - Select if applicable to your company Climbers equipped with full body harness 100% tie off when climbing either by use of a safety climb system, double leg lanyard or 2 lanyards Personnel platform meets regulations and the pre-lift protocol completed Insured agrees that any use of sub contractors hired will be required to meet the same safety standards the insured is required to meet Insured maintains written records of all safety audits and each employee’s safety training records are easily accessible for inspection purposes Rf/eme hazards reviewed Daily hoist inspections performed and documented per asse a10.48 standard and osha cpl 02-01-056 Proper controls in place for adverse weather conditions – including but no limited to high winds, lightning, rain and ice Provide procedures if climb is scheduled during bad weather or other poor conditionsAre Drones used to Inspect Towers?* Yes No N/A Max height of drone use*Pilot FAA Part 107 Certifications* Yes No Other Describe procedures for airspace authorization Crane/ Equipment/ Installation ExposuresPlease Select Not Applicable Do you rent cranes on short term basis?* Yes No Please provide copies of all the Crane lease/rental agreement that includes terms and conditions if leasing/renting cranes with or without operator Drop files here or Select files Max. file size: 100 MB. Do you always lease/rent cranes with an operator?* Yes No Do you provide certified riggers for working with the crane?* Yes No Do you provide certified and trained crane spotter and signal personnel?* Yes No Do you use multiple crane/ tandem lifts?* Yes No Average value “on hook”?*Revenue from rigging operations?*Do you lease/rent your equipment to others?* Yes No Do you lease/rent equipment valued over $100,000?* Yes No Do you have equipment with previous water/wind damage?* Yes No Do you store materials of others at your location?* Yes No What is the maximum value you have at one time?*Do you own or long term lease cranes?* Yes No Provide description of the crane(s) including VIN and values.*What are your annual expenditures for rented equipment?*What are your annual installation revenues?* Are you requesting WC coverage? Yes No Do you allow employees to work more than 12 consecutive hours? Yes No <5051-100101-250>250Does the applicant accept emergency calls? Yes No Do any employees work from home? Yes No Number of employees who live/work out of state?Average Annual Employee TurnoverIn %How do you pay your employees? Hourly Piece Rate Commission Flat Rate Other Any interchange of labor between entities or other companies? Yes No If yes, please explainDo you use any day laborers or temporary/leased employees? Yes No Do you use union employee? Yes No If yes, what %?What is the average hourly wage for employees that work in the field?Do you have a 401k, retirement or pension plan? Yes No If yes, do you as an employer contribute it to? Yes No Do you have group medical coverage for your employees? Yes No If yes, what percentage of employees are enrolled?What percentage is paid by you the employer? Work Premises and Equipment informationDoes your safety program include heat illness prevention? Yes No Has any insurance company performed a loss control survey on your company in the last year? Yes No Has CAL/OSHA visited/cited your business in the last year? Yes No Do you have formal documentation of your safety training with your employees? Yes No How often do you conduct safety training? Daily Weekly Monthly Quarterly Other How often are safety meetings conduced?MSDS (material safety data sheets) available for all chemicals/products used? Yes No What is the maximum manual lifting? 25 lbs 25-50 lbs 51-100 lbs > 100 lbs Forklift training provided? Yes No If yes, annual certification? Yes No Check any of the following types of equipment used: Ladders Scaffolding Scissor Lifts Bucket Lifts Welding Equipment Other, please describeDoes all machinery/equipment have proper guards? Yes No Condition of equipment used: New Good Average If scaffolding used, does the insured build their own? Yes No If yes, provide the % of annual operations involving scaffolding setup and teardown compared to total operationsDoes your company have Written lockout/tagout/blockout procedures in place? Yes No N/A Do you require strict enforcement of use of PPE, safety protocols, etc? Yes No N/A Estimated number of jobs per year?Are your employees subjected to any confined spaces exposures? Yes No If yes, please describe:Does your company do any welding? Yes No If yes, please describe:Do you complete a JHA (jobsite hazard analysis) before every job? Yes No HR ProcessesPlease check all that applies to your company* Background checks on all potential employees conducted Drug free certificate for my state Employee handbook Post-Accident drug test Pre-Employment drug test Pre-Employment or Post physical Random employee drug test References checked upon hire Review of potential employees social media N/A Are you a member of another association?* Yes No Please list*Please provide any additional information regarding your company that you feel will help underwriters when they are looking at your accountNumber of full time safety personnel*Number of part time safety personnel*How often do you have field safety audits*Safety Director Name(s) and Email(s)NameEmail Add Remove Industry InvolvementIs your company a member of NATE? Yes No Is your company a member of WIA? Yes No Is your company a member of any other association? Yes No If yes, please list: Submission Requirements• ACORD Applications • Copy of safety program and auto safety program • Complete loss ratio spreadsheet including all premiums and claims • Copy of Subcontractor Agreement (if applicable) • Crane lease agreement if leasing cranes with or without operator • Current Mod History • Currently valued loss runs for past 5 years (if less, provide number of years in business) • Details on all claims $10K or greater • Most recent experience Mod worksheet How did you hear about the USA Telecom program? Avetta Crown Castle NATE USA Telecom Marketing Website Other Describe OtherSignature (typed) of person completingCompleted by Agent Insured This field is hidden when viewing the formDate MM slash DD slash YYYY