Note: RESIDENTIAL means single-family dwellings, multi-family dwellings, condominiums, townhomes, townhouses, apartments and cooperatives.
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1 Kinsale Insurance Company P. O. Box Richmond, VA (804) ROOFING CONTRACTOR S SUPPLEMENTAL APPLICATION COMPLETE IN ADDITION TO ACORD APPLICATIONS. ATTACH ADDITIONAL SHEETS AS NECESSARY. ANSWER ALL QUESTIONS. If not applicable, indicate N/A. APPLICANT S INFORMATION APPLICANT S NAME: MAILING ADDRESS: STREET ADDRESS (if different): CITY, STATE, ZIP CODE: CONTACT PERSON: PHONE NUMBER: GENERAL INFORMATION Note: RESIDENTIAL means single-family dwellings, multi-family dwellings, condominiums, townhomes, townhouses, apartments and cooperatives. 1. Indicate the percentage of work to be performed by you or on your behalf by subcontractors during the next twelve months: Residential % + Commercial/Industrial % = 100% 2. Indicate the percentage of work performed by you or on your behalf by subcontractors during the past five years: Residential % + Commercial/Industrial % = 100% 3. Indicate the percentage of RESIDENTIAL work to be performed by you or on your behalf by subcontractors: Single-Family Dwellings % Condominiums, Townhomes and Townhouses % Apartments and Cooperatives % Page 1 of 5
2 4. Indicate the percentage of RESIDENTIAL ROOFING work that is: New construction % TYPE OF ROOF WORK PERCENTAGE Repair/patching % Hot tar % Replacement % Tile % Shingles % On pitched roofs? % Slate % On flat roofs % Metal % Single Ply % Other (describe) % 5. Indicate the percentage of COMMERCIAL/INDUSTRIAL ROOFING work that is: New construction % TYPE OF ROOF WORK PERCENTAGE Repair/patching % Hot tar % Replacement % Tile % Single Ply % On pitched roofs % EPDM % On flat roofs % Shingles % Built Up % PVC % Metal Other (describe) % 6. Check work done other than roofing: Waterproofing Siding Asbestos removal Rain gutters Carpentry Insulation EIFS/Synthetic Stucco Other (describe): 7. Describe the work performed on your behalf by subcontractors including the cost for each category: Page 2 of 5
3 8. Provide exposure history for the past three years and your estimates for the next 12 months: YEAR DIRECT LABOR PAYROLL AMOUNT PAID TO SUBS GROSS REVENUES NEXT 12 MONTHS 9. Are all subcontractors hired under a standard written subcontractor s agreement? Yes No (attach a copy) 10. What are the standard insurance requirements for your subcontractors? 11. Are certificates of insurance collected from all subcontractors? Yes No How long are they retained? 12. Provide details if you rent cranes or other equipment from others including whether rented with or without operator and the corresponding cost of such rentals: 13. Indicate the number of cranes you own or lease long-term from others (please attach schedule). 14. If hot tar is used or torch work is performed, explain in detail the process and safety precautions used to prevent fires during and after work hours: 15. Indicate the percentage of work to be performed involving the use of torches: % Is all such work performed by employees certified by the National Roofing Contractors Association Yes No or a similar industry organization? 16. Explain the precautions used to prevent weather infiltration: 17. Indicate the height of buildings on which you perform work: Average: stories Maximum: stories 18. Explain your employee fall-protection procedures: 19. Indicate the number of employees who are: Union Non-Union 20. Indicate the average wage of your hourly workforce: per hour 21. Do you employ casual or temporary labor? Yes No If yes, are such workers covered by your Workers Compensation insurance? Yes No Page 3 of 5
4 22. Do you hire employees or independent contractors through employment agencies? Yes No If yes, who is responsible for maintaining Workers Compensation insurance for such workers? 23. Are the employment agencies responsible for performing background checks on such Yes No workers including verification of United States citizenship, valid Green Cards or valid Work Visas? 24. Indicate the number of job supervisors and foremen you employ: 25. Are all jobs inspected by a job supervisor or foreman upon completion of work but before Yes No leaving the job site? If yes, please explain in detail: 26. Are you a member of the National Roofing Contractors Association? Yes No Membership Identification #: FRAUD WARNING NOTICE TO ALABAMA, ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, CONNECTICUT, DELAWARE, GEORGIA, IDAHO, ILLINOIS, INDIANA, IOWA, KANSAS, MARYLAND, MASSACHUSETTS, MICHIGAN, MINNESOTA, MISSISSIPPI, MISSOURI, MONTANA, NEBRASKA, NEVADA, NEW HAMPSHIRE, NORTH CAROLINA, NORTH DAKOTA, OREGON, RHODE ISLAND, SOUTH CAROLINA, SOUTH DAKOTA, TEXAS, UTAH, VERMONT, WASHINGTON, WEST VIRGINIA, WISCONSIN, AND WYOMING APPLICANTS: In some states, any person who knowingly, and with intent to defraud any insurance company or other person, files an application for insurance or statement of claim containing any materially false information, or, for the purpose of misleading, conceals information concerning any fact material thereto, may commit a fraudulent insurance act which is a crime in many states. NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or information to a policy holder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claiming with regard to a settlement or award payable for insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of claim containing any false, incomplete or misleading information is guilty of a felony of the third degree. NOTICE TO HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both. NOTICE TO KENTUCKY APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. NOTICE TO MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines, or denial of insurance benefits. NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. NOTICE TO NEW MEXICO APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties. NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud an insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed $5,000 and the stated value of the claim for each such violation. Page 4 of 5
5 NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. NOTICE TO OKLAHOMA APPLICANTS: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes a any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. NOTICE TO PENNSYLVANIA APPLICANTS: Any person who knowingly and with intent to defraud any insurance company, or other person, files an application for insurance or statement of a claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties. NOTICE TO TENNESSEE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. NOTICE TO VIRGINIA APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. The Applicant acknowledges that the answers provided herein are based on a reasonable inquiry and/or investigation. The Applicant warrants that the above statements and particulars together with any attached or appended documents are true and complete and do not misrepresent, misstate or omit any material facts. The Applicant agrees to notify us of any material changes in the answers to the questions on this questionnaire which may arise prior to the effective date of any policy issued pursuant to this questionnaire and the Applicant understands that any outstanding quotations may be modified or withdrawn based upon such changes at our sole discretion. Completion of this form does not bind coverage. Applicant s acceptance of the company s quotation is required prior to binding coverage and policy issuance. All written statements and materials furnished to the company in conjunction with this application are hereby incorporated by reference into this application and made a part of this application. Applicant: Title: FEIN #: Applicant s Signature: Date: Agent/Broker Name: Page 5 of 5
PIPELINE CONSTRUCTION SUPPLEMENTAL APPLICATION
Kinsale Insurance Company P. O. Box 17008 Richmond, VA 23226 (804) 289-1300 www.kinsaleins.com NAMED INSURED S INFORMATION PIPELINE CONSTRUCTION SUPPLEMENTAL APPLICATION COMPLETE IN ADDITION TO ACORD APPLICATIONS.
Roofing Supplemental Application
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COLLECTION AGENCY ERRORS & OMISSIONS APPLICATION
Kinsale Insurance Company P. O. Box 17008 Richmond, VA 23226 (804) 289-1300 www.kinsaleins.com COLLECTION AGENCY ERRORS & OMISSIONS APPLICATION APPLICANT S INFORMATION 1. Legal name of the business who
Hired and Non-Owned Liability Supplemental Application All questions must be answered in full. Application must be signed and dated by the applicant.
Agency Name: Address: Contact Name: Phone: Fax: Email: Applicant s Name Hired and Non-Owned Liability Supplemental Application All questions must be answered in full. Application must be signed and dated
Employee Leasing/Temporary Employment Agency Application
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MARIJUANA SUPPLEMENTAL APPLICATION
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Machinery, Equipment And Rigging Supplemental Application
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Pedicab Companies. Commercial General Liability Application
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Welding Supply/Gas Distributor Supplemental Application
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1) Has applicant had previous insurance for this enterprise? Yes No If yes, provide the following information:
Kinsale Insurance Company P. O. Box 17008 Richmond, VA 23226 (804) 289-1300 www.kinsaleins.com WELDING OPERATIONS SUPPLEMENTAL APPLICATION COMPLETE IN ADDITION TO ACORD APPLICATIONS. ATTACH ADDITIONAL
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INSURANCE AGENTS AND BROKERS ERRORS & OMISSIONS APPLICATION
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Lexington Insurance Company Administrative Offices: 99 High Street, Floor 23 Boston, Massachusetts 02110-2378 SEND APPLICATIONS AND INQUIRIES TO: 1438-F West Main Street, Ephrata, PA 17522-1345 800.640.7601;
Madison National Life Insurance Company, Inc. P.O. BOX 2865 CLINTON, IA Telephone: Extension 2410 Fax:
EMPLOYEE S STATEMENT OF CLAIM FOR BENEFITS As your disability insurer we are committed to assisting you in a return to health and to productive employment. Please complete the following form as thoroughly
Kentucky , ,349 55,446 95,337 91,006 2,427 1, ,349, ,306,236 5,176,360 2,867,000 1,462
TABLE B MEMBERSHIP AND BENEFIT OPERATIONS OF STATE-ADMINISTERED EMPLOYEE RETIREMENT SYSTEMS, LAST MONTH OF FISCAL YEAR: MARCH 2003 Beneficiaries receiving periodic benefit payments Periodic benefit payments
LOCUM TENENS AND CONTRACT STAFFING APPLICATION
Kinsale Insurance Company P. O. Box 17008 Richmond, VA 23226 (804) 289-1300 www.kinsaleins.com LOCUM TENENS AND CONTRACT STAFFING APPLICATION Instructions to the Applicant please complete this application
State Individual Income Taxes: Personal Exemptions/Credits, 2011
Individual Income Taxes: Personal Exemptions/s, 2011 Elderly Handicapped Blind Deaf Disabled FEDERAL Exemption $3,700 $7,400 $3,700 $7,400 $0 $3,700 $0 $0 $0 $0 Alabama Exemption $1,500 $3,000 $1,500 $3,000
WORKERS' COMPENSATION - FIRST REPORT OF INJURY OR ILLNESS
WORKERS' COMPENSATION - FIRST REPORT OF INJURY OR ILLNESS EMPLOYER (NAME & ADDRESS INCL ZIP) CARRIER / ADMINISTRATOR CLAIM NUMBER * REPORT PURPOSE CODE * JURISDICTION * JURISDICTION LOG NUMBER * INSURED
1. Risk Classification Provide detailed description of your business operations including target clientele:
RESTAURANT / BAR / TAVERN OR SIMILAR ESTABLISHMENT SUPPLEMENTAL APPLICATION WITH OPTIONAL LIQUOR LIABILITY TO BE COMPLETED IN ADDITION TO ACORD APPLICATION OR ITS EQUIVILENT Applicant s Name: Agent: Applicant
Loss/Collision Damage Waiver HOW TO FILE A CLAIM
Loss/Collision Damage Waiver HOW TO FILE A CLAIM 1. Complete all items on the attached claim form. 2. Attach the following documents (as applicable): Copy of rental car agreement Copy of police report
Abuse And Molestation Liability Application
Abuse And Molestation Liability Application THIS APPLICATION IS ON AN OCCURRENCE COVERAGE BASIS THIS APPLICATION IS ON A CLAIMS-MADE COVERAGE BASIS NOTICE: THIS APPLICATION IS FOR A COVERAGE PART WRITTEN
Instructions for Completing this Application GENERAL INFORMATION. 1. Name of Applicant: 2. Business Address:
This completed document should be submitted to: ALTRU, LLC 3975 Erie Avenue Cincinnati, OH 45208 T: 800-529-8850 www.altru.com OLD REPUBLIC INSURANCE COMPANY MISCELLANEOUS PROFESSIONAL LIABILITY APPLICATION
GUARANTEE TRUST LIFE INSURANCE COMPANY Credit Claim Service Center P.O. Box 1145 Glenview, IL Phone: Fax:
Initial Credit Disability Claim Form GUARANTEE TRUST LIFE INSURANCE COMPANY Credit Claim Service Center P.O. Box 1145 Glenview, IL 60025 Phone: 800-592-0629 Fax: 847-460-2962 Office Hours: Monday thru
Accidental Death HOW TO FILE A CLAIM
Accidental Death HOW TO FILE A CLAIM 1. Complete all items on the attached claim form. 2. Attach the following documents (as applicable): Certified copy of death certificate (Required for all claims) Certified
How to Apply for Long Term Disability Conversion Insurance
How to Apply for Long Term Disability Conversion Insurance Please follow these steps to apply for Conversion: 1. Complete the LTD Conversion Application provided in this package. Please answer each question
Piers, Wharves & Docks Application
POLICY TO BE ISSUED IN THE NAME OF: MAILING ADDRESS: PRODUCER S NAME: AGENCY ADDRESS: CITY: STATE: ZIP: CITY: STATE: ZIP: REQUESTED EFFECTIVE DATES: FROM: TO: PRODUCER PHONE: PRODUCER FAX: INSURED IS: