Applicant is:
Individual
Corporation
Partnership
Joint Venture
Other
Year(s) in Business:
Year(s) in Experience:
Inspection (Contact/Phone)
Radius Of Operations:
Miles
NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS:
LARGE LOSSES (Losses Over $10,000):
ANY SUITS UNDER BREACH OF WARRANT?
No
Yes (if Yes, explain):
DEDUCTIBLE:
Per Claim Bodily Injury & Property Damage
$500
$1,000
GENERAL INFORMATION (Explain
all "Yes" responses below)
INDICATE TYPE OF CONSTRUCTION WORK PERFORMED BY INSURED
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 |
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1. Any exposures
to flammables, explosives, and/or chemicals? |
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2. Any demolition? |
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3. Any catastrophe
exposure? |
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4. Does operations
involve storing, treating, discharging, applying or transporting
of
hazardous materials? |
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5. Has applicant
ever been involved in and/or will be involved in multiple unit structures
(including condos, townhouses, apartments)? |
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6. Has applicant
ever acted as a and/or will act as a subcontractor on tract home
subdivisions? |
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7. Does owner
supervise daily jobs or operations directly? |
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8. Does applicant
lease equipment from others? |
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9. Is machinery/equipment
loaned, rented or leased to others?
with/
without operator? |
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10. Does applicant
draw up plans, designs or specifications? |
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11. Does applicant
perform work above two (2) stories? |
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12. Does applicant
hold other people's property for service or repair? |
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13. Does applicant
perform any work below grade (maximum depth =
feet)? |
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14. Does applicant
always check with local utilities authority before digging? |
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15. Does
applicant dig or grade next to existing foundations or other structures? |
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16. Does applicant
do any tunneling or other underground work? |
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17. Does applicant
do any spray painting? |
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18. Has the
applicant done, within the past three (3) years, or will be doing
any roofing or any
operations associated with roofing? |
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19. Has applicant
performed other types of operations not associated with any aforementioned
operations? |
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20. Does applicant
repair swimming pools or install swimming pool accessories (diving
boards,
slides, etc.?) |
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21. Has the
applicant ever worked on any of the following (check appropriate
boxes):
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Explain
all "Yes" Responses:
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SUBCONTRACTOR EXPOSURE:
Cost
of All Subcontractor Work: $
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.
Person
Completing Application
Date
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