Applicant's Name:
Mailing Address:
City
State
Zip
Phone:
Fax:
PROPOSED
EFFECTIVE DATE:
From
To
Email:
Applicant is:
Individual
Corporation
Partnership
Joint Venture
Additional
Insured
Other
# Year(s) in Business:
# Year(s) Experience:
Inspection (Contact/Phone)
Radius Of Operations:
Miles
PREMISES
INFORMATION
#
Address
Interest
Year Built
Part Occupied
NATURE OF
BUSINESS/DESCRIPTION OF
OPERATIONS:
PREVIOUS
INSURER
(Indicate
Premium & Losses
for Past 3
Years):
Year
Company
Policy #
Premium
# Claims
Pd Losses
Res Losses
Description
LARGE LOSSES (Losses Over
$10,000):
ANY SUITS UNDER BREACH
OF WARRANT?
No
Yes (if Yes, explain):
COVERAGES
LIMITS
Yes
No Additional
Insured
($100
each)
General Aggregate
$
00,000
Products/Completed
Operations Aggregate
$
00,000
Personal &
Advertising
$
00,000
Each Occurrence
$
00,000
Fire Damage (any one
fire)
$ 50,000
Medical Expense
$ 5,000
DEDUCTIBLE: Per Claim
Bodily Injury & Property
Damage
$500
$1,000
SCHEDULE
OF HAZARDS
Classification:
Class Code:
Number of Employees:
(include Owner and
any active Partners
as full-time
employees)
Owners:
Employees:
ESTIMATED
RECEIPTS: $
ESTIMATED
PAYROLL: $
Past
three
(3)
Years
Receipts
Payroll
Number
of
Employees
CLASSES OF
CONTRACTORS
LICENSE(S) INSURED
HOLDS:
License #
License #
License #
GENERAL
INFORMATION (Explain all
"Yes" responses below)
Yes
No
1. Is applicant a
subsidiary of
another entity or
does the applicant
have any
subsidiaries?
2. Any operations
outside of
contracting?
3. Any policy or
coverage declined,
cancelled or not
renewed during the
past three (3)
years?
4. Has applicant
ever been involved
in another business
venture?
5. Does applicant
sponsor any sporting
or social events?
6. Does applicant
own any (check
appropriate boxes):
Real Property
Mobile Home
Land for Speculation
Other
7. Does applicant
have a Safety
Program in place?
8. Has applicant
ever been denied a
performance bond?
9. Has a claim ever
been filed with the
applicant's bonding
company on a
performance bond for
applicant?
GENERAL INFORMATION
Explanation of “Yes”
Responses:
INDICATE TYPE OF
CONSTRUCTION WORK PERFORMED
BY INSURED
Carpentry
%
Maintenance
%
Sewer
%
Concrete
%
Masonry
%
Steel (Ornamental)
%
Drilling
%
Mechanical
%
Steel (Structural)
%
Electrical
%
Painting
%
Street/Road
%
Excavating
%
Plastering
%
Supervisory Only
%
Gas Mains
%
Plumbing
%
Tunneling
%
Insulation
%
Roofing
%
Other
%
INDICATE %
OF WORK PERFORMED
IN:
New Construction
%
Commercial
%
Inside Building
%
Remodeling
%
Industrial
%
Outside Building
%
Demolition
%
Residential
%
Other
%
Repair
%
Institutional
%
LIST ALL CURRENT/PAST
PROJECTS FOR LAST 12 MONTHS
(Include description of
project and its cost)
UNDERWRITING
INFORMATION (Explain
all "Yes" responses
below):
Yes
No
1. Any exposures to
flammables,
explosives, and/or
chemicals?
2. Any demolition?
3. Any catastrophe
exposure?
4. Does operations
involve storing,
treating,
discharging,
applying or
transporting of
hazardous materials?
5. Has applicant
ever been involved
in and/or will be
involved in multiple
unit structures
(including condos,
townhouses,
apartments)?
6. Has applicant
ever acted as a
and/or will act as a
subcontractor on
tract home
subdivisions?
7. Does owner
supervise daily jobs
or operations
directly?
8. Does applicant
lease equipment from
others?
9. Is
machinery/equipment
loaned, rented or
leased to others?
with/
without operator?
10. Does applicant
draw up plans,
designs or
specifications?
11. Does applicant
perform work above
two (2) stories?
12. Does applicant
hold other people's
property for service
or repair?
13. Does applicant
perform any work
below grade (maximum
depth =
feet)?
14. Does applicant
always check with
local utilities
authority before
digging?
15. Does applicant
dig or grade next to
existing foundations
or other structures?
16. Does applicant
do any tunneling or
other underground
work?
17. Does applicant
do any spray
painting?
18. Has the
applicant done,
within the past
three (3) years, or
will be doing any
roofing or any
operations
associated with
roofing?
19. Has applicant
performed other
types of operations
not associated with
any aforementioned
operations?
20. Does applicant
repair swimming
pools or install
swimming pool
accessories (diving
boards,
slides, etc.?)
21. Has the
applicant ever
worked on any of the
following (check
appropriate boxes):
Railroads
Septic Tanks
Right of
Ways
Retaining
Walls
Irrigation
Projects
Sewer Mains
Drainage
Projects
Flood
Control
Bridges
Gas Lines
Explain all "Yes"
Responses:
SUBCONTRACTOR EXPOSURE:
Cost of All Subcontractor
Work: $
List Subcontractor
Trades Being Used
and % of Each:
1)
%
5)
%
2)
%
6)
%
3)
%
7)
%
4)
%
8)
%
1. Does applicant require
Certificates of Insurance
from subcontractors?
Yes
No
2. What limits does
applicant require
subcontractors carry?
3. Does applicant require
to be named on all
subcontractors General
Liability policies?
Yes
No
REMARKS:
Does applicant have any
prior claims and any
knowledge of potential
claims from their operations
prior to policy inception?
Yes
No If yes, explain.
