COMMERCIAL GENERAL LIABILITY APPLICATION

Transcription

1 Roush Insurance Services, Inc. Agency Code PO Box 1060, Noblesville IN Address Ph: (800) Fax: (317) City State Zip Phone Fax Applications available at COMMERCIAL GENERAL LIABILITY APPLICATION Proposed Dates: From to DBA Individual Partnership Corporation Other Applicant Name Inspection Contact Mailing Address Location Address City State Zip City State Zip Phone: Day Evening Website Business Description Length of Time in Business/Experience yrs mos New Venture? No Yes Non-Profit? No Yes Prior Carrier Expiring Premium $ Lapse in Coverage? No Yes, Reason Any Claims in Last Three Years? No Yes, Describe and Attach Loss Runs Has any Company Cancelled or Refused Coverage to the Applicant? No Yes, Reason DESIRED LIMITS & COVERAGES (Please Note: Quotation may not conform to limits and coverages requested on application.) LIABILITY LIMITS $ Per Occurrence / $ Aggregate Estimated Annual Employee Payroll (excluding all owners): $ Total Number of Owners: Estimated Annual Receipts: $ Premises Area: sq ft Apartments? No Yes, How many? Are Subcontractors Utilized in Applicant s Operations? No Yes, Estimated Annual Cost of Subcontractors: $ Do Subcontractors Carry Same or Greater Liability Limits? No Yes Are Certificates of Insurance Required? No Yes Is there a Parking Lot on Premises for Customers? No Yes, Size sq ft, Maintained by Any Bodies of Water on Premises? No Yes, acres / ft deep, Protective Measures in Place? No Yes Describe Description of Operations (Mark all that apply and describe in detail): Storing, treating, discharging, applying, disposing of or transporting hazardous materials Demolition, blasting, utilization or storage of explosive materials Welding or cutting Excavation, tunneling, underground work or earth moving Loaning or renting machinery or equipment to others Installing, servicing or demonstrating products Manufacturing products or parts Selling or distributing foreign products or parts Selling or repackaging products under applicant s label Drawing plans, designs, or specifications Sponsoring sporting or social events Does Applicant use Cranes? No Yes, Maximum Size Capacity Length of Boom ft Are any New Operations Planned in the Next Twelve Months? No Yes, Describe Does Applicant Provide Guarantees, Warranties or Hold Harmless Agreements? No Yes, Describe Lessor s Risk? No Yes, Does Applicant Require Proof of Liability Insurance from All Commercial Tenants? No Yes Is Applicant Listed as Additional Insured on All Commercial Tenants General Liability Policies? No Yes Hours of Operation: Mon-Thu Fri Sat Sun CommlGenLiab Page 1 of 2 Ed 10/10

2 Other Business on Premises? No Yes, Describe Additional Insured Interest Mailing Address City State Zip Other Pertinent Information: FRAUD WARNING: 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 conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Not applicable in Nebraska, Oregon and Vermont. NOTICE TO OHIO APPLICANTS: Any person who knowingly and with intent to defraud any insurance company 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 subjects such person to criminal and civil penalties. APPLICANT SIGNATURE AGENT SIGNATURE DATE DATE CommlGenLiab Page 2 of 2 Ed 10/10

3 Name of Applicant: Web Site Address: Roush Insurance Services, Inc. PO Box 1060 Noblesville, IN Phone (800) Fax (317) ANIMAL SERVICES PROGRAM SUPPLEMENTAL APPLICATION (Completed in addition to the General Liability Application) 1. Description of operations/services provided. Indicate annual sales for each of the following described classes: Description of Operations/Services Annual Sales Description of Operations/Services Annual Sales Animal Catchers (dog, cat, chicken, etc.) Other Training Operations: Animal Catchers Other Describe: Exotic Animal Training for Use in TV, Movie, Commercials, Videos or Theatrical Shows Behavioral/Psychiatry Consultant Drug, Explosives or Firearms Detection Excrement and/or Carcass Removal Services Guard Animal Training or operations Guide/Companion Animal Training Horse Training Hunt Dog Training Kennels: Horse Riding Instruction Riding Academies Breeding, Boarding or Sales Animal Shows or Contests Animal Adoption Services or Foster Care Animal Hotel and/or Pet Day Care Center Animal Rides Incl. Sleigh/Carriage Rides Pony Sweeps Animal Shelter Livestock: Humane Society Auctions Gift and/or Thrift Shops Artificial Insemination Services Obedience Schools Breeding Pet Grooming Incl. Mobile Grooming Dealers Pet Store Pet Sitters Pet Walkers Therapy Dog Training or Services Petting Zoos Stables (boarding, livery or racing) Veterinarian Services Veterinary Hospitals or Clinics Other Describe: GLS-APP-70s (11-06) Page 1 of 3

4 2. Kennels Breeding, Boarding or Sales, Animal Shelters, Humane Societies: Kennel is defined as each individual compartment used for housing an animal. Indicate total number of kennels/compartments: 3. Animal Adoption Services Including Foster Care, Animal Hotels, Pet Day Care Centers (Not Kennels, Animal Shelters or Humane Societies): Indicate average daily number of animals under your care: 4. Any other premises or operations exposures not stated in this application?... Yes No If yes, explain: 5. Do you provide Therapy Dog services?... Yes No a. Have all dogs used in this service passed the American Kennel Clubs Canine Good Citizen Test or equivalent and have additional required training to have certification/title as a Therapy Dog?... Yes No b. Name of organization or association that has provided certification: 6. Check the following if you are a member of the organization: American Animal Hospital Association (AAHA) American Boarding Kennels Association (ABKA) American Society for the Prevention of Cruelty to Animals (ASPCA) American Humane Association (AHA) American Veterinary Medical Association (AVMA) Humane Society of the United States (HSUS) Intergrom National Association of Dog Obedience Instructors National Association of Professional Pet Sitters National Dog Groomers Association of America, Inc. (NDGAA) Pet Industry Joint Advisory Council Society of Dog Trainers Other Describe: 7. Are you licensed by the United States Department of Agriculture (USDA)?... Yes No License Number: 8. Do you follow the practices and regulations of the Animal Welfare Act?... Yes No 9. a. Do you import animals?... Yes No b. Are you a licensed customs importer subject to regulation by the U.S. Department of Customs?... Yes No 10. Kennels Breeding Type of animal: Dog Cat Other Describe: Breed(s): Number of litters sold per year:... Total number of animals sold per year:... GLS-APP-70s (11-06) Page 2 of 3

5 FRAUD WARNING: 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 conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. FRAUD WARNING (APPLICABLE IN TENNESSEE AND WASHINGTON): 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. FRAUD WARNING APPLICABLE IN THE STATE OF NEW YORK: 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 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 five thousand dollars and the stated value of the claim for each such violation. APPLICANT S NAME AND TITILE: APPLICANT S SIGNATURE: PRODUCER S SIGNATURE: (Must be signed by an active owner, partner or executive officer.) DATE: DATE: GLS-APP-70s (11-06) Page 3 of 3