General Contractors Supplemental Application
|
|
|
- Miles Wells
- 6 years ago
- Views:
Transcription
1 General Contractors Supplemental Application APPLICANT INFORMATION Applicant Name: AKA / DBA: Mailing Address: Loc Address: Area of Ops: Insured Contact: Website: Yrs in Business: Yrs Experience: Phone: GENERAL INFORMATION Licenses Held License # # Owner / Partners Payroll Projected Cost Subcontracted Work (labor & materials) Insured Uninsured Total Receipts OPERATIONS Please provide a breakdown of your work as: General Contractor % Subcontractor % Developer % Construction Manager / Consultant Only % % of Work Breakdown % % New % Remodel Tot New/Remodel Residential 100% Commercial 100% Industrial 100% Total Work 100% If new residential construction work is being done, please indicate type: Apartments % Condos/Townhouses % Custom Homes % Tract Homes % Provide a description of the type of work done by you and your employees: Have you operated or been licensed under any other name(s) during the past 10 years? If Yes, provide prior name and describe type of operations: Seneca General Contractors Supplemental 1 09/09
2 Indicate percentage of payroll for each type of construction work performed by your employees: Alarm Systems % Excavating % Rigging % Asbestos/Lead Removal % Fire Proofing % Roofing % Blasting % Fire Restoration % Seismic Retrofitting % Boiler Work % Foundation % Septic Tank % Boring % Framing of Buildings % Sewer % Bridges/Elevated Roads % Gas Mains % Sheet Metal Work % Building Raising/Moving % Grading of Land % Siding % Caisson/Cofferdam Work % Insulation % Soil Stabilization % Cantilevered Construction % Landscaping % Steel (ornamental) % Carpentry % Maintenance % Steel (structural) % Communication Lines % Masonry % Street/Road Construction % Concrete % Mechanical % Stevedoring % Construction Defect Remediation % Mold & Spore Remediation % Supervisory Only % Dam/Reservoir Construction % % Swimming Pools % Debris Removal % Oil & Gas Fields % Tile/Stone/Marble % Demolition % Painting % Tunneling % Dredging % Pile Driving % Underpinning/Shoring % Drilling % Pipeline/Water Main % Waterproofing % Dywall % Plastering % Water Restoration % Earthquake Reinforcement % Plumbing % Welding % EIFS % Power Lines % Other: % Electrical % Process Piping % Equipment Rental to Others % Removal/Installation of % Total 100 % Underground Tanks Any construction of the following? Airports Nuclear Plants Railroads Stadiums Subways SUBCONTRACTOR INFO / RISK TRANSFER Indicate type of construction work performed by your subcontractors: Alarm Systems % Excavating % Rigging % Asbestos/Lead Removal % Fire Proofing % Roofing % Blasting % Fire Restoration % Seismic Retrofitting % Boiler Work % Foundation % Septic Tank % Boring % Framing of Buildings % Sewer % Bridges/Elevated Roads % Gas Mains % Sheet Metal Work % Building Raising/Moving % Grading of Land % Siding % Caisson/Cofferdam Work % Insulation % Soil Stabilization % Cantilevered Construction % Landscaping % Steel (ornamental) % Carpentry % Maintenance % Steel (structural) % Communication Lines % Masonry % Street/Road Construction % Concrete % Mechanical % Stevedoring % Construction Defect Remediation % Mold & Spore Remediation % Supervisory Only % Dam/Reservoir Construction % % Swimming Pools % Debris Removal % Oil & Gas Fields % Tile/Stone/Marble % Demolition % Painting % Tunneling % Dredging % Pile Driving % Underpinning/Shoring % Drilling % Pipeline/Water Main % Waterproofing % Dywall % Plastering % Water Restoration % Earthquake Reinforcement % Plumbing % Welding % EIFS % Power Lines % Other: % Electrical % Process Piping % Equipment Rental to Others % Removal/Installation of % Total 100 % Underground Tanks Are all subcontractors required to sign a hold harmless and indemnification agreement in your favor? If No, please explain: Are Certificates of Insurance obtained from subcontractors? Seneca General Contractors Supplemental 2 09/09
3 Do you require all subs to have equal limits? Are you named as an additional insured on all subcontractors policies? Do you normally use the same subcontractors? If you are a Project Manager/Consultant, do you contract with the subcontractors? OTHER Any work performed above four stories in height? Maximum number of stories: Any work performed below grade? Maximum depth: Is scaffolding owned, rented or erected? Are other contractors at the job site allowed to use it? Any mobile equipment leased from others? Type of equipment leased? Are operators provided? Do you have a formal safety program in force? Do you have Workers compensation coverage in force? Any employees working under: U.S. Longshoremen s and Harborworkers Act? Jones Maritime Act? Do you or any of your employees hold a Real Estate Agent s license? Do you own any vacant land? If Yes, is property zoned: Residential Commercial Number of acres: Do you plan to develop this property within the next policy term? If Yes, please provide details: Have you ever been involved in any construction defect claims? If Yes, please provide details: Do you participate in any owner-controlled insurance program (OCIP) or Wrap- Up insurance? Does applicant have other business ventures for which coverage is not requested? If Yes, explain and advise where insured: Has the applicant or majority partner filed for bankruptcy within the past five years? CURRENT OR RECENT PROJECTS Project Description Cost of Project Duration LOSS INFORMATION Was prior coverage ever cancelled or non- If Yes, please explain: Loss information for the past 3 years: No losses No prior coverage Yes No Year # 0f Claims Incurred Amounts Description Seneca General Contractors Supplemental 3 09/09
4 FRAUD STATEMENT Applicable in Arkansas, Louisiana, and West Virginia 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. Applicable in Colorado 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 policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant 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. Applicable in District of Columbia 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. Applicable in Florida 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. Applicable in Hawaii 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. Applicable in Kentucky 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. Applicable in Maine 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 a denial of insurance benefits. Applicable in Maryland Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Applicable in New Jersey Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. Applicable in New Mexico 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 tocivil fines and criminal penalties. Applicable in 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. Applicable in Ohio Any person who, with intent to defraud or knowing that he 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. Applicable in Oklahoma WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. Applicable in Pennsylvania 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. Applicable in Rhode Island The insurance application form shall indicate the existence of a criminal penalty for failure to disclose a conviction of arson. Applicable in Tennessee, Virginia, 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. Seneca General Contractors Supplemental 4 09/09
5 SIGNATURES I hereby certify that all information is accurate to the best of my knowledge. Applicant s Name and Title: Applicant s Signature: Producer s Signature: Date: Date: Seneca General Contractors Supplemental 5 09/09
GENERAL CONTRACTORS & PROJECT MANAGERS SUPPLEMENTAL APPLICATION
EVERGREEN INSURANCE MANAGERS INC License #: CA 0G35858 ID 146979 OR 100167092 WA 702962 www.evergreenins.com GENERAL CONTRACTORS & PROJECT MANAGERS SUPPLEMENTAL APPLICATION APPLICANT INFORMATION Applicant
GENERAL CONTRACTORS/DEVELOPERS GENERAL LIABILITY APPLICATION
Scottsdale Insurance Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 Adm. Office: 8877 North Gainey Center Drive Scottsdale, Arizona 85258 Scottsdale Indemnity Company Home Office: One Nationwide
General Contractors/Developers General Liability Application
General Contractors/Developers General Liability Application Applicant s Name Mailing Address Agency Name Agent Address Web Site Address E-Mail Phone PROPOSED EFFECTIVE DATE: From To 12:01 A.M., Standard
GENERAL CONTRACTORS/DEVELOPERS GENERAL LIABILITY APPLICATION
GENERAL CONTRACTORS/DEVELOPERS GENERAL LIABILITY APPLICATION Applicant s Name: Agency Name: Agent No.: Mailing Address: Address: Location Address: E-mail: Phone No.: PROPOSED EFFECTIVE DATE: From To 12:01
General Contractors/Developers General Liability Application
General Contractors/Developers General Liability Application ANSWER ALL QUESTIONS IF THEY DO NOT APPLY, INDICATE NOT APPLICABLE. Applicant s Name _ Agent Name Address Mailing Address PROPOSED EFFECTIVE
GENERAL CONTRACTORS/DEVELOPERS GENERAL LIABILITY APPLICATION
GENERAL CONTRACTORS/DEVELOPERS GENERAL LIABILITY APPLICATION Applicant s Name: Agency Name: Agent: Mailing Address: Address: Location Address: E-mail: Phone No.: PROPOSED EFFECTIVE DATE: From To 12:01
General Contractors/Developers General Liability Application
Home Office: One Nationwide Plaza Columbus, Ohio 43215 Administrative Office: 8877 North Gainey Center Drive Scottsdale, Arizona 85258 1-800-423-7675 Fax (480) 483-6752 www.scottsdaleins.com General Contractors/Developers
Company Type: Corporation LLC Partnership Individual Joint Venture If Joint Venture, please describe: Additional Named Insured s (if any)
CONTRACTOR S POLLUTION LIABILITY APPLICATION SECTION 1 APPLICANT INFORMATION Applicant (Full Legal Name): Physical Address of Applicant: Mailing Address of Applicant: City: State: Zip Code: Established:
GENERAL CONTRACTORS/DEVELOPERS GENERAL LIABILITY APPLICATION
Mid Valley General Agency LLC 888 Madison St NE, Ste 100, Salem, OR 97301 Phone: 888-565-7001 Fax: 888-265-7353 quotes@midvalleyga.com GENERAL CONTRACTORS/DEVELOPERS GENERAL LIABILITY APPLICATION Applicant
ARTISAN CONTRACTORS SUPPLEMENTAL APPLICATION (Complete in addition to ACORD General Liability Application)
ARTISAN CONTRACTORS SUPPLEMENTAL APPLICATION (Complete in addition to ACORD General Liability Application) Applicant s Name: Mailing Address: Agency Name: Agent: Phone: PROPOSED EFFECTIVE DATE: From To
FORECLOSURE/EVICTION CLEANUP SUPPLEMENTAL APPLICATION (Complete in addition to ACORD General Liability Application)
FORECLOSURE/EVICTION CLEANUP SUPPLEMENTAL APPLICATION (Complete in addition to ACORD General Liability Application) Name of Applicant: Web site Address: State/Area of Operations: ANSWER ALL QUESTIONS IF
CONTRACTOR S SUPPLEMENTAL APPLICATION
CONTRACTOR S SUPPLEMENTAL APPLICATION Note: Throughout this questionnaire the words you and your include all entities seeking coverage. Name(s) of Applicant: Address: Years in Business*: Years Experience:
Contractors Application
Agency Name: Address: Contact Name: Phone: Fax: Email: Contractors Application All questions must be answered in full. Application must be signed and dated by the applicant. APPLICANT S NAME AND MAILING
CONTRACTORS GENERAL LIABILITY SUPPLEMENTAL APPLICATION
AGENT FIRST NAME: AGENT LAST NAME AGENT EMAIL: FIRST NAME: LAST NAME: DBA: BUSINESS NAME: BUSINESS TYPE: COUNTY: PRIMARY LOCATION ADDRESS: CITY: STATE: ZIP: MAILING ADDRESS: CITY: STATE: ZIP: WEB ADDRESS:
Company Type: Corporation LLC Partnership Individual Joint Venture
ENVIRONMENTAL CONTRACTOR & CONSULTANT APPLICATION SECTION 1 APPLICANT INFORMATION Applicant (Full Legal Name): Mailing Address of Applicant: City: State: Zip Code: Telephone: Website: Environmental Contact
GENERAL CONTRACTORS APPLICATION
GENERAL CONTRACTORS APPLICATION Instructions 1. Please complete this application. All questions must be answered. (If None or Not Applicable so indicate) 2. If space is insufficient to complete answers,
ARTISAN CONTRACTORS SUPPLEMENTAL APPLICATION (Complete in addition to ACORD General Liability Application)
Scottsdale Insurance Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 Adm. Office: 8877 North Gainey Center Drive Scottsdale, Arizona 85258 Scottsdale Surplus Lines Insurance Company Adm.
Application for Contractors Pollution Liability
Application for Contractors Pollution Liability APPLICANT INFORMATION applicant: address: city: state: company is a(n): individual year established: contact: phone: email address: zip: partnership corporation
Demolition Contractors (Per Job Basis) General Liability Application
Demolition Contractors (Per Job Basis) General Liability Application Applicant s Name: Agency Name: Agent: Mailing Address: Address: Location Address: E-mail: Phone: Web site Address: PROPOSED EFFECTIVE
IF YES TO THE ABOVE, PLEASE RESPOND TO THE FOLLOWING QUESTIONS. IF NO, PLEASE SIGN, DATE AND RETURN TO THE UNDERWRITER.
Hartford Fire Insurance Company UNDERWRITING QUESTIONNAIRE SERVICING CONTRACTORS NAME OF INSURED: 1. Do you currently use independent contractors for servicing loans? IF YES TO THE ABOVE, PLEASE RESPOND
FORECLOSURE/EVICTION CLEANUP SUPPLEMENTAL APPLICATION (Complete in addition to ACORD General Liability Application)
FORECLOSURE/EVICTION CLEANUP SUPPLEMENTAL APPLICATION (Complete in addition to ACORD General Liability Application) Applicant s Name: Mailing Address: Agency Name: Agent No.: Phone No.: PROPOSED EFFECTIVE
CONTRACTORS GENERAL LIABILITY APPLICATION
CONTRACTORS GENERAL LIABILITY APPLICATION PREQUALIFICATION 1. Are you involved (past, present or intended future) in residential construction (new, remodeling, installation or repair), and/or development
CONTRACTORS PROJECT-SPECIFIC POLICY SUPPLEMENTAL Tel: (847) West High Street, Somerville, NJ
CONTRACTORS PROJECT-SPECIFIC POLICY SUPPLEMENTAL Tel: (847) 208.8847 198 West High Street, Somerville, NJ 08876 www.axonu.com NOTE: THIS IS AN APPLICATION FOR A PROJECT-SPECIFIC POLICY OR ENDORSEMENT This
Package Liability Insurance Policy for
Package Liability Insurance Policy for Members Provided by Insurance by APPLICATION FORM You must be an active NARI member to qualify for this insurance. Please answer all questions completely, leaving
IRONSHORE INSURANCE INC. One State Street Plaza, 8 th Floor New York, NY Tel: Toll Free: (877) IRON-411
IRONSHORE INSURANCE INC. One State Street Plaza, 8 th Floor New York, NY 10004 Tel: 646-826-6600 Toll Free: (877) IRON-411 CONSULTANTS PROFESSIONAL LIABILITY INSURANCE APPLICATION THE APPLICANT IS APPLYING
TELECOMMUNICATION CONTRACTORS SUPPLEMENTAL APPLICATION (Complete in addition to the ACORD General Liability Application)
Scottsdale Insurance Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 Scottsdale Indemnity Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 1-800-423-7675 Fax (480) 483-6752
Artisan Contractors Application
Artisan Contractors Application All questions must be answered in full. Application must be signed and dated by the applicant. APPLICANT S NAME AND MAILING ADDRESS AGENT / PRODUCER INFORMATION APPLICANT
CONSTABLE PROFESSIONAL LIABILITY APPLICATION
CONSTABLE PROFESSIONAL LIABILITY APPLICATION Provide responses to the inquiries on this application. If necessary, provide detailed responses on the last page. I. APPLICANT INFORMATION 1. Name : Address:
Contractors Equipment Rental General Liability Application
Surplus Call 800-342-5706 Insurance Fax 800-578-7758 www.surplusins.com Brokers Email quotes: submit@surplusins.com Agency Inc. P O Box 749, South Bend IN 46624-0749 Contractors Equipment Rental General
ARTISAN CONTRACTORS SUPPLEMENTAL APPLICATION (Complete in addition to ACORD General Liability Application)
ARTISAN CONTRACTORS SUPPLEMENTAL APPLICATION (Complete in addition to ACORD General Liability Application) Applicant s Name: Agency Name: Mailing Address: Agent No.: Phone No.: PROPOSED EFFECTIVE DATE:
Demolition Contractors (Per Job Basis) General Liability Application
Demolition Contractors (Per Job Basis) General Liability Application Applicant s Name: Agency Name: Agent: Mailing Address: Address: Location Address: E-mail: Phone: Web site Address: PROPOSED EFFECTIVE
Arch Specialty Insurance Company Administrative Office: One Liberty Plaza, 53 rd Floor, New York, NY 10006
Arch Specialty Insurance Company Administrative Office: One Liberty Plaza, 53 rd Floor, New York, NY 10006 Application for Contractors Pollution Liability Insurance This insurance coverage you are applying
Railroad Protective Liability Coverage (Attach/Submit ACORD 801)
1. Applicant Information: A. Name Insured Railroad: Railroad Protective Liability Coverage (Attach/Submit ACORD 801) 1. DBA: 2. Address: 3. City: State: Zip Code: B. Name Designated Contractor: 1. DBA:
FORECLOSURE/EVICTION CLEANUP SUPPLEMENTAL APPLICATION (Complete in addition to ACORD General Liability Application)
Roush Insurance Services, Inc. PO Box 1060 Noblesville, IN 46061-1060 Phone: (800) 752-8402 Fax: (317) 776-6891 www.roushins.com Email: quote@roushins.com FORECLOSURE/EVICTION CLEANUP SUPPLEMENTAL APPLICATION
Hiscox Insurance Company Inc.
If coverage is issued, it will be on a Claims made basis. Notice: Unless the Claim Expenses outside the limit option is required to be included by the relevant state regulation or is selected by the Applicant,
Commercial General Liability Application
> Commercial General Liability Application All questions must be answered in full. Application must be signed and dated
ACE Privacy Protection Privacy & Network Liability Insurance Program Renewal Application
ACE Privacy Protection Privacy & Network Liability Insurance Program Renewal Application NOTICE The Policy for which you are applying is written on a claims made and reported basis. Only claims first made
TELECOMMUNICATION CONTRACTORS SUPPLEMENTAL APPLICATION
TELECOMMUNICATION CONTRACTORS SUPPLEMENTAL APPLICATION Applicant s Name: Agent Name: Agent Address: Location Address: Phone No.: PROPOSED EFFECTIVE DATE: From To 12:01 A.M., Standard Time at the address
Contractors General Liability Supplemental Questionnaire
Contractors General Liability Supplemental Questionnaire Applicant Name: Mailing Address: Years in business under current name: 1. If this is a new operation, please provide details on prior experience
Commercial General Liability Application
Commercial General Liability Application All questions must be answered in full. Application must be signed and dated by the applicant. Applicant s Name Agent Applicant Mailing Address Applicant s Phone
CONTRACTORS GENERAL LIABILITY APPLICATION
CONTRACTORS GENERAL LIABILITY APPLICATION PREQUALIFICATION (Refer to Contractor or General Contractor SMART Cards in the Underwriting Guide for additional restrictions) 1. Are you involved (past, present
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
SUPPLEMENTAL APPLICATION
RAILROAD INSURANCE PROGRAM SUPPLEMENTAL APPLICATION Applicant Name: Date Completed: Address: City/State/Zip: Contact Name: Website address: Phone Number: Additional program information can be found at
AXIS PRO MULTIMEDIA LIABILITY COVERAGE RENEWAL APPLICATION FOR INSURANCE
AXIS PRO MULTIMEDIA LIABILITY COVERAGE RENEWAL APPLICATION FOR INSURANCE I. GENERAL INFORMATION 1. First Named Insured (including DBAs): Gibson Overseas, Inc. NOTE: First Named Insured is responsible for
EMPLOYEE STOCK OWNERSHIP PLAN RENEWAL QUESTIONNAIRE
EMPLOYEE STOCK OWNERSHIP PLAN RENEWAL QUESTIONNAIRE Name of Insurance Company to which application is made COMPLETION OF THIS QUESTIONNAIRE IS REQUIRED WHEN SEEKING COVERAGE FOR A STANDALONE EMPLOYEE STOCK
OIL & GAS CONTRACTORS SUPPLEMENT (Must be fully completed and attached to the application)
SEND SUBMISSIONS TO: TEXAS coverxtx@coverx.com www.coverx.com NEW JERSEY coverxse@coverx.com Producer: Producer Is: Wholesaler Retailer Address: Telephone: Fax: Excess & Surplus Lines License No.: Email:
Roofing Supplemental Application
Roofing Supplemental Application TO BE USED WITH COMMERCIAL GENERAL LIABILITY APPLICATION (ACORD 125) All questions must be answered in full. Application must be signed and dated by the applicant. APPLICANT
Environmental Contractors & Consultants Liability Insurance Application MPA Environmental
Environmental Contractors & Consultants Liability Insurance Application MPA Environmental 20595 Lorain Road Fairview Park, OH 44126 (800) 545-1538 INSTRUCTIONS: This form must be completed, dated and signed
APPLICATION FOR FIDUCIARY LIABILITY COVERAGE PART
APPLICATION FOR FIDUCIARY LIABILITY COVERAGE PART THIS APPLICATION IS FOR A CLAIMS-MADE POLICY. "CLAIMS" MUST BE FIRST MADE AGAINST AN "INSURED PERSON" DURING THE "POLICY PERIOD" OR ANY APPLICABLE EXTENDED
Contractors Equipment Rental General Liability Application. Agency Name: Agent: Address: Phone No.:
Roush Insurance Services, Inc. PO Box 1060 Noblesville, IN 46061-1060 Phone: (800) 752-8402 Fax: (317) 776-6891 www.roushins.com Email: quote@roushins.com Contractors Equipment Rental General Liability
TRUST COMPANIES Underwriting Questionnaire
Harford Fire Insurance Company TRUST COMPANIES Underwriting Questionnaire Name of Applicant: 1. Is dual control exercised over all discretionary trust accounts (two employees, regardless of whether outside
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:
TELECOMMUNICATION TOWERS SUPPLEMENTAL APPLICATION (Complete in addition to the ACORD General Liability Application)
TELECOMMUNICATION TOWERS SUPPLEMENTAL APPLICATION (Complete in addition to the ACORD General Liability Application) Applicant s Name: Agent Name: Agent Address: Location Address: Phone No.: PROPOSED EFFECTIVE
Crane And Rigging Supplemental Application
> Crane And Rigging Supplemental Application TO BE USED WITH COMMERCIAL GENERAL LIABILITY APPLICATION (ACORD 125) All
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.
Employee Leasing/Temporary Employment Agency Application
Employee Leasing/Temporary Employment Agency Application All questions must be answered in full. Application must be signed and dated by the applicant. Applicant s Name Agent Applicant Mailing Address
PRIVATE COMPANY SUPPLEMENTAL CLAIM FORM
PRIVATE COMPANY SUPPLEMENTAL CLAIM FORM Name of Insurance Company to which application is made INSTRUCTIONS: This form is to be completed by an Applicant who has been involved in any claim or suit during
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
THE HARTFORD CRIMESHIELD SM ADVANCED POLICY BOND SMALL BUSINESS APPLICATION FOR EMPLOYEE THEFT CLIENT PREMISES ONLY
< >, a stock insurance company, herein called the Insurer THE HARTFORD CRIMESHIELD SM ADVANCED POLICY BOND SMALL BUSINESS APPLICATION FOR EMPLOYEE THEFT CLIENT PREMISES ONLY AGENCY NAME: HARTFORD AGENCY
ENVIRONMENTAL SERVICES PACKAGE POLICY APPLICATION ECO-PAK (SM) New Business
ENVIRONMENTAL SERVICES PACKAGE POLICY APPLICATION ECO-PAK (SM) New Business Submission Requirements In order for us to provide quotations by the date needed, the following required information must be
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
AXIS Insurance Telephone: (678) S. Wacker Dr., Ste Toll-Free: (866) Chicago, IL Facsimile: (678)
AXIS Insurance Telephone: (678) 746-9000 111 S. Wacker Dr., Ste. 3500 Toll-Free: (866) 259-5435 Chicago, IL 60606 Facsimile: (678) 746-9315 Website: www.axiscapital.com/en-us/insurance/us#professional-lines
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
Machinery, Equipment And Rigging Supplemental Application
Machinery, Equipment And Rigging Supplemental Application TO BE USED WITH COMMERCIAL GENERAL LIABILITY APPLICATION (ACORD 125) All questions must be answered in full. Application must be signed and dated
RENEWAL APPLICATION CONTRACTORS AND CONSULTANTS
Please submit the following information: 1) Two years financials including balance sheet and income statement. 2) At least 3 yrs loss runs (not including those years written with Berkley Specialty Underwriting
MISCELLANEOUS PROFESSIONAL LIABILITY APPLICATION
MISCELLANEOUS PROFESSIONAL LIABILITY APPLICATION CLAIMS MADE AND REPORTED FORM ALL QUESTIONS MUST BE ANSWERED IN FULL. APPLICATION MUST BE SIGNED AND DATED BY THE PRINCIPAL, OFFICER OR PARTNER APPLICANT
Property/Casualty Insurance Renewal Survey
P.O. Box 5670 Cortland, NY 13045 Phone (800) 822-3747 Fax: (607) 756-5051 Email: applications@ mcneilandcompany.com GENERAL INFORMATION Date of survey: Renewal Date: Date proposal needed: Legal Name of
SPECIAL EVENT SUPPLEMENTAL APPLICATION
SPECIAL EVENT SUPPLEMENTAL APPLICATION SUBMISSION REQUIREMENTS Currently valued insurance company loss runs for the current policy period plus three (3) prior years (for accounts where premium exceeds
ID Theft Insurance HOW TO FILE A CLAIM
ID Theft Insurance HOW TO FILE A CLAIM 1. Complete all items on the attached claim form. 2. Attach the following documents (as applicable): The completed claim form Copy of all correspondence, police reports,
AXIS Insurance Telephone: (678) S. Wacker Dr., Ste Toll-Free: (866) Chicago, IL Facsimile: (678)
AXIS Insurance Telephone: (678) 746-9000 111 S. Wacker Dr., Ste. 3500 Toll-Free: (866) 259-5435 Chicago, IL 60606 Facsimile: (678) 746-9315 Website: www.axiscapital.com/en-us/insurance/us#professional-lines
Note: RESIDENTIAL means single-family dwellings, multi-family dwellings, condominiums, townhomes, townhouses, apartments and cooperatives.
Kinsale Insurance Company P. O. Box 17008 Richmond, VA 23226 (804) 289-1300 www.kinsaleins.com ROOFING CONTRACTOR S SUPPLEMENTAL APPLICATION COMPLETE IN ADDITION TO ACORD APPLICATIONS. ATTACH ADDITIONAL
Critical Illness Insurance Insured s Statement (Please print Attach separate sheet if additional space required) Insured s Name Claim#:
Critical Illness Insurance Insured s Statement (Please print Attach separate sheet if additional space required) INSURED INFORMATION Insured s Name Claim#: Soc. Sec. No. - - Date of Birth / / (MM/DD/YY)
EMPLOYEE STOCK OWNERSHIP PLAN QUESTIONNAIRE
EMPLOYEE STOCK OWNERSHIP PLAN QUESTIONNAIRE Name of Insurance Company to which application is made COMPLETION OF THIS QUESTIONNAIRE IS REQUIRED WHEN SEEKING COVERAGE FOR A STANDALONE EMPLOYEE STOCK OWNERSHIP
PROPOSED INSURED (APPLICANT):
PROPOSED INSURED (APPLICANT): 1. Name of the Applicant s firm: Street Address: City, State, Zip Code: Website address(es): 2. A. Provide the date the Applicant s firm was established: B. Geographic area
Solar or Wind Energy Facilities Application
Solar or Wind Energy Facilities Application All questions must be answered in full. Application must be signed and dated by the applicant. APPLICANT S NAME AND MAILING ADDRESS AGENT / PRODUCER INFORMATION
EXCAVATORS AND GRADING OF LAND SUPPLEMENTAL APPLICATION (Complete in addition to ACORD General Liability Application)
Scottsdale Insurance Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 Adm. Office: 8877 North Gainey Center Drive Scottsdale, Arizona 85258 Scottsdale Indemnity Company Home Office: One Nationwide
PLEASE READ THE POLICY CAREFULLY
CRIME INSURANCE APPLICATION - MASSACHUSETTS PLEASE READ THE POLICY CAREFULLY Please fully answer all questions and submit all requested information. Terms
376 Broadway, PO Box 1038, Schenectady, NY Toll free: 877- MERRIAM ( )
376 Broadway, PO Box 1038, Schenectady, NY 12301-1038 Toll free: 877- MERRIAM (637-7426) TITLE AGENT PROFESSIONAL LIABILITY - ERRORS AND OMISSIONS INSURANCE APPLICATION THIS IS A CLAIMS MADE AND REPORTED
Exterminators General Liability Application
Exterminators General Liability Application Applicant s Name: Agency Name: Agent: Mailing Address: Address: Web site Address: E-mail: Phone: PROPOSED EFFECTIVE DATE: From To 12:01 A.M., Standard Time at
OCEAN MARINE SHIPWRIGHT PROGRAM INSURANCE APPLICATION
OCEAN MARINE SHIPWRIGHT PROGRAM INSURANCE APPLICATION Completing this form does not bind the Applicant to complete this insurance, but it is agreed that this form shall be the basis of the contract should
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
PRIVATE COMPANY THIRD PARTY ADMINISTRATOR QUESTIONNAIRE
PRIVATE COMPANY THIRD PARTY ADMINISTRATOR QUESTIONNAIRE NAME OF APPLICANT COMPANY (or you ): ADDRESS: DATE: 1. Do clients audit you to the extent of the service you provide them? a. How is the audit performed?
HOME INSPECTORS PROFESSIONAL LIABILITY INSURANCE APPLICATION THIS INSURANCE, IF ISSUED, WILL BE ON A CLAIMS-MADE AND REPORTED BASIS.
800 Oak Ridge Turnpike, Suite A-1000 Oak Ridge, Tennessee 37830 HOME INSPECTORS PROFESSIONAL LIABILITY INSURANCE APPLICATION THIS INSURANCE, IF ISSUED, WILL BE ON A CLAIMS-MADE AND REPORTED BASIS. NOTICE:
APPLICATION FOR Social Services Not-For-Profit Management Liability
APPLICATION FOR Social Services t-for-profit Management Liability Section A. APPLICANT INFORMATION: Name of Applicant: Address: Website address: Description of Services or purpose of Organization: Number
NON-PROFIT ORGANIZATION MANAGEMENT LIABILITY RENEWAL APPLICATION
NON-PROFIT ORGANIZATION MANAGEMENT LIABILITY RENEWAL APPLICATION NOTICE: THIS IS A CLAIMS MADE AND REPORTED POLICY THAT APPLIES ONLY TO THOSE CLAIMS FIRST MADE AGAINST THE INSURED DURING THE POLICY PERIOD
SECUREXCESS APPLICATION FOR AN EXCESS POLICY
SECUREXCESS APPLICATION FOR AN EXCESS POLICY NOTICE: SUBJECT TO THE PROVISIONS OF THE UNDERLYING INSURANCE, THIS POLICY MAY ONLY APPLY TO CLAIMS FIRST MADE AGAINST THE INSUREDS DURING THE POLICY PERIOD
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
REAL ESTATE APPRAISERS PROFESSIONAL LIABILITY APPLICATION - RENEWAL AMERICAN ACADEMY OF STATE CERTIFIED APPRAISERS, A RISK PURCHASING GROUP
Lexington Insurance Company Administrative Offices: 100 Summer Street, Boston, Massachusetts 02110 SEND APPLICATIONS AND INQUIRIES TO: 1438-F West Main Street, Ephrata, PA 17522-1345 800.640.7601; 717.721.3500;
Condominium/Homeowners Association Application
> Applicant s Name Condominium/Homeowners Association Application All questions must be answered in full. Application
Present Crime Insurance Program: (Include primary AND excess, if applicable) If not applicable, please check here:
, a stock insurance company, herein called the Insurer The Hartford CrimeSHIELD Advanced Policy EMPLOYEE THEFT CLIENT PREMISES (THEFT OF CLIENT S PROPERTY APPLICATION) Agency Name: Billing Method: Agency/Broker
Contractors General Liability Application
SURPLEX UNDERWRITERS, INC. www.surplexuw.com SURPLEX UNDERWRITERS, PO BOX 998 PORTLAND, ME. 04104, FAX 207-856-0260, PHONE 800-441-1799 SURPLEX UNDERWRITERS, PO BOX 10477, BEDFORD, NH. 03110, FAX 603-625-4869,
EVENT PARTY OR WEDDING PLANNER SUPPLEMENTAL APPLICATION
EVENT PARTY OR WEDDING PLANNER SUPPLEMENTAL APPLICATION Applicant s Name TO BE USED WITH COMMERCIAL GENERAL LIABILITY APPLICATION (ACORD 125) All questions must be answered in full. Application must be
FACILITIES POLLUTION MOLD COVERAGE SUPPLEMENTAL APPLICATION
Environmental 505 Eagleview Boulevard Suite 100 PO Box 636 Exton, PA 19341-0636 USA Tel: 800-327-1414 610-968-9500 Fax: 610-458-8667 www.xlenvironmental.com FACILITIES POLLUTION MOLD COVERAGE SUPPLEMENTAL
CONTRACTORS POLLUTION LIABILITY APPLICATION
CONTRACTORS POLLUTION LIABILITY APPLICATION THIS IS AN APPLICATION FOR EITHER A CLAIMS-MADE OR OCCURRENCE FORM POLICY All questions must be answered completely. If space is insufficient to complete answers
Demolition Contractors Annual Policy General Liability Application
Demolition Contractors Annual Policy General Liability Application Agency Name: Agent: Phone number: Address: City/State: Zip code: E-mail address: Fax number: Applicant s Name: APPLICANT INFORMATION Street
Part One Small Firm Application for Miscellaneous Professionals Liability
Part One Small Firm Application for Miscellaneous Professionals Liability Contractors Bonding and Insurance Company Peoria, Illinois 61615 This application applies to firms with revenues less than $1,000,000.
AXIS PRO MISCELLANEOUS PROFESSIONAL LIABILITY APPLICATION
AXIS PRO MISCELLANEOUS PROFESSIONAL LIABILITY APPLICATION WHAT THE APPLICANT SHOULD KNOW ABOUT THIS APPLICATION: CLAIMS MADE POLICY This application is for a CLAIMS MADE POLICY. Claims made coverage applies
MISCELLANEOUS PROFESSIONAL LIABILITY APPLICATION
MISCELLANEOUS PROFESSIONAL LIABILITY APPLICATION CLAIMS MADE AND REPORTED FORM ALL QUESTIONS MUST BE ANSWERED IN FULL. APPLICATION MUST BE SIGNED AND DATED BY THE PRINCIPAL, OFFICER OR PARTNER Applicant
SWIMMING POOL CONTRACTORS, DEALERS AND INSTALLERS SUPPLEMENTAL APPLICATION (Complete in addition to ACORD General Liability Application)
SWIMMING POOL CONTRACTORS, DEALERS AND INSTALLERS SUPPLEMENTAL APPLICATION (Complete in addition to ACORD General Liability Application) Applicant s Name: Agency Name: Agent No.: Location Address: Phone
APPRAISAL MANAGEMENT COMPANY PROFESSIONAL LIABILITY APPLICATION
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;