KMRD - OCP Questionnaire - Use this one TM

*If the request requires immediate action please contact our staff by phone so we can support you in the timeframe you require. 866-957-KMRD (5673)

KMRD Client Information:

Your Name: *

Phone Number: *

Email Address: *

KMRD Client Company Name: *

KMRD Account Manager:

Named Insured / Owner Information:

Legal Name of Insured / Owner: *

Years in Business:

Street Address: *

Address Line 2:

City: *

State: *

Zip Code: *

Contractor / Construction Manager Information:

Name of Contractor / Construction Manager: *

Street Address:

Address Line 2:

City:

State:

Zip Code:

Description of Covered Project:

Description of Covered Project: *

0/250 characters

Contract/Project Number:

Location: 🛈

Check if Applicable. Yes Answers Require Explanation Below:

	Check If Applicable and Explain Below
Watercraft/Aircraft	Check If Applicable and Explain Below
Storing of Inflammable Gases, Liquids, and Explosives	Check If Applicable and Explain Below
Hazardous Waste Removal or Installation	Check If Applicable and Explain Below
Drilling	Check If Applicable and Explain Below
Blasting	Check If Applicable and Explain Below
Scaffolding	Check If Applicable and Explain Below
Surrounding Property Damage Exposure	Check If Applicable and Explain Below
At, On, or Near a Landfill Site	Check If Applicable and Explain Below
Synthetic Stucco	Check If Applicable and Explain Below
Bridge or Overpass Work	Check If Applicable and Explain Below
Tunnels	Check If Applicable and Explain Below
Asbestos, Mold, or Lead Abatement	Check If Applicable and Explain Below
Dam, Reservoir, Jetty, Breakwaters, Piers, Docks, or Wharfs	Check If Applicable and Explain Below
Surrounding Property Damage Exposure	Check If Applicable and Explain Below
Potential Third Party Bodily Injury Exposure	Check If Applicable and Explain Below
Special Jobsite Safety Precautions	Check If Applicable and Explain Below

If Any of the above are checked, please provided further explanation here:

0/500 words

Estimated Cost of Completed Contract: *

Information Outlined in Job Specs: *

	Information Outlined in Job Specs
a. Proposed Starting Date	Information Outlined in Job Specs
b. Job Term in Calendar Days	Information Outlined in Job Specs
c. Estimated Completion Date	Information Outlined in Job Specs

	Type of Subcontractors	Percent of Subcontracted (%)
a.	Type of Subcontractors	Percent of Subcontracted (%)
b	Type of Subcontractors	Percent of Subcontracted (%)
c.	Type of Subcontractors	Percent of Subcontracted (%)
d.	Type of Subcontractors	Percent of Subcontracted (%)
e.	Type of Subcontractors	Percent of Subcontracted (%)

For the following questions, please read these instructions carefully.

For each section you can either enter each of the requested items OR attach documents or contracts that you may have pertaining to each of the requested information. Please do not attach the same document or contract twice. One upload will be sufficient for KMRD Partners, Inc. to find all the necessary information for you.

Attach Any Contract or Indemnification Agreement Between Owner and Contractor:

Limits of Coverage:

Aggregate Limit:

Occurrence Limit:

Details of Hold Harmless Agreements:

a. Between Contractor and Subcontractors:

b. Between Contractor and Insured:

Additional Insureds:

Additional Insured #1

Company Name:

First Name of Contact:

Last Name of Contact:

Title:

Contact Phone Number:

Contact Email Address

Street Address:

Address Line 2:

City:

State:

Zip Code:

Additional Insured #2

Company Name:

First Name of Contact:

Last Name of Contact:

Title:

Contact Phone Number:

Contact Email Address:

Street Address:

Address Line 2:

City:

State:

Zip Code:

If more than two Additional Insureds, please list them here:

Thank you for utilizing this system. You should recieve confirmation of your request via email. A KMRD representative will reach out to you with questions if we have them. If you do not hear from us, feel free to call at 866-957-KMRD (5673) or contactus@kmrdpartners.com

This form is for communication purposes only. This form does not bind coverage.