5 Whittier Street, Framingham, MA 01701
Main: 508.656.1400, Fax: 508.656.1499
Hours of Operation: M-F, 8:00 a.m. - 5:00 p.m. EST
Available weekends and nights by appointment
info@charlesriverinsurance.com
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As our company grew, it was important to choose an insurance broker who had the knowledge and experience to provide complete, comprehensive insurance coverage for our specific needs. Charles River Insurance met all of these requirements. They are involved from the beginning stages of evaluating potential new building acquisitions to working with our lenders developing insurance solutions for each property’s unique risk. Working with Charles River Insurance continues to be one of our best business decisions.
 
Brian Poitras, Principal
Calare Properties, Inc.
  
  Client Services
 
Arborists Supplemental Questionnaire

Named Insured:  Policy Number: 
Title:   
Policy Period:  Account Number: 
Named Insured - Please list all named insured including both past and current entities.
  Named Insured Active / Inactive Length of Time in Operation
1    
2    
3    
Description of Insured's Operations (include all entities listed above)
States Performing Operations:         Other: 

Indicate the percentage of the risk�s operation which falls into each of the following categories
Tree service work for governmental bodies, public utilities or railroads (clearing for utility lines)  %
Land Clearing  %
Tree Moving Services (include description of process; size of tree, distance transported):
 %
Selling garden supplies  %
Work performed for timberland owners  %
Snow removal (% for parking lots:  roads:  driveways:  highways:  )  %

Do you or have you ever performed, directly or through a subcontractor, any of the following work
(If �Yes� or �Subbed� please describe further in Comment section below):
Airport  
Agricultural crop spraying  
Automatic Sprinkler/Fire Suppression (indoor)  
Blasting  
Environmental Remediation  
Equipment Rental without Operators  
Fire/Water Damage Restoration  
Logging  
Site preparation including rough & finish grading  
Utility line clearance or maintenance work  
Comment  
Percentage of Subcontracted Work:  % (Based on Total Job Costs)

CONTRACTUAL CONTROLS/RISK TRANSFER
 
Are contracts required for all subcontracted work?  
Does the contract contain a hold harmless agreement?  
Does the contract contain an indemnification agreement?  
Are certificates of insurance obtained from subcontractors for:  
General Liability?  
Workers Compensation?  
Is there a diary system in place to track expiration dates for certificates of insurance?  
Are subcontractors required to carry at least $1,000,000 occ/$2,000,000 agg?  
Do you require subcontractors to name you as an additional insured?  
Do your subcontractors always utilize contracts with the same provisions noted above?  
   

Please Attach a Copy of Your Subcontractor Agreement (MANDATORY REQUIREMENT)
 
Do you have a formal safety program?  
Have you had any OSHA violations in the past 5 years?  
Do you post active work areas with signs?  
Do you have a formal maintenance program with daily documented vehicle inspection?  
Do you own/operate chippers or grinders?  
If yes;  
Is equipment equipped with fire extinguishers? How often is the system serviced?   
Is there an automatic fire suppression system?  
Do employees remain on site until machinery cools down?  
Is there a formal maintenance program and are records kept?  
Are employees certified Arborists?  
Any current or past (5 years) involvement in:     
Have you ever been named in a pollution suit?  
Have you ever been named in claims and/or litigation regarding faulty or defective
construction or workmanship including subsidence or EIFS?		  
Do you have knowledge of any pre-existing act, omission, event, condition or damages to any person or property that may potentially give rise to any future claim or legal action?  
   

COMMERCIAL AUTOMOBILE
 
HIRING PRACTICES / DRIVER SELECTION PROCEDURES
1) Is a written application required?  
2) Are reference checks made?  
3) Is there an over the road examination (if driving vehicle over 26,000 GVW)?  
4) Is drug / alcohol testing required before hiring (for CDL drivers)?  
5) Is a personal interview of prospective driver conducted?  
6) Are MVR�s drawn on all new drivers and annually on all current drivers?  
7) Are physical examinations required for new drivers?  
   
Describe what criteria would disqualify drivers from employment:
Accidents / violations:
Minimum driving age:  Maximum driving age: 
Minimum driving experience (as CDL holder): 
Other: 
 

CHEMICAL APPLICATIONS EXPOSURES
 
Please indicate types of restricted chemicals used and maximum amount in storage at any one time
in each of the types of containers indicated in the table below:
 
Active Ingredient 55 Gal. Drums Gal. Tanks Lb. Bags Active Ingredient 55 Gal. Drums Gal. Tanks Lb. Bags
Acrolein       Methyl parathion      
Aldicarb       Paraquat      
Conitralid       Phorate      
Dicrotophos       Phosphamidon      
Disulfoton       Picloram      
Ethyl parathion       Sodium cyanide      
Methamidophos       Sodium fluoroacetate      
Methidathion       Strychnine      
Methomyl       Sulfotepp      
Methyl bromide       Other:       

List all employees holding EPA licenses
Lic. Type License # Name of LIcensee Expires Experience
         
         
         
         
         

Any independent contractors used for application of restricted chemicals?  
If yes, confirm that subs are incompliance with contractual risk transfer procedures above  
Please indicate the estimated amount of subcontract cost for coming year   Actual prior year 
What kind of personal protective equipment is used? 
Who is responsible for training employees who mix chemicals? 
What is the ratio of crew level unlicensed applicators to licensed applicators on staff (eg. 5:1)? 
Are mixing procedures primarily?  
Occupants are notified verbally?  
Post application flagging and/or placarding of property?  
   
Does the insured maintain the following records for at least 2 years?  
Location of pesticide application  
Date, time and weather conditions at time of application  
Trade name, EPA registration number and amount of pesticide applied  
Type, amount location and method of pesticide disposal  
   
   
   
   
   

 
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