LLEGANY CO-OP INSURANCE COMPANY 9 NORTH BRANCH ROAD, CUBA, NY, 14727 ARTISAN ACE-14 POLICY APPLICATION APPLICANT'S NAME AND MAILING ADDRESS Name: Street: AGENCY: AGENT CODE: City: Zip Code: State: County: HOME PHONE: BUSINESS PHONE: PHONE: FAX: INDIVIDUAL EFFECTIVE DATE EXPIRATION DATE PARTNERSHIP LLC CORPORATION OTHER (specify): PAYMENT PLAN Names of partners or LLC or corporation owners: ANNUAL 4-PAY 6-PAY 1. OPERATIONS Fully describe ALL operations 2. BASIC APPLICANT HISTORY AND INFORMATION A. Number of years applicant in business B. Number of years experience in this trade class C. Does applicant operate any other business not described on this application? YES NO D. Does applicant work as a contractor on a part-time basis? YES NO If yes, describe E. Previous Insurer (past 5 years) Policy No. Policy No. F. Loss History Check if None Date of Loss Description of Loss Amount Paid or Reserve Corrective Action G. Number of Employees, not including owner(s): Full Time Part Time H. Is account new to your agency? YES NO If no, how many years has your agency had the account? I. Accounting Records are available at: Check if address is same as mailing Name, Address, Phone Ed. 11/16 1
3. UNDERWRITING QUESTIONNAIRE Any Yes answers must be fully explained A. Do receipts exceed 500,000 per year? YES NO B. Does the insured have less than three years experience in this line of business? YES NO C. Does the insured have more than 4 employees? YES NO D. Is the insured a general contractor? YES NO E. Does the insured subcontract more than 25% of their work to others? YES NO F. Does the insured require others to be listed as additional insureds? YES NO G. Does the insured perform operations not described on Allegany classification list? YES NO H. Do more than 10% of the insured s receipts involve work on commercial property? YES NO I. Does the insured mix or apply chemicals, fertilizers, pesticides, or other harmful chemicals? YES NO J. Does the insured perform operations involving repair, installation, or service of commercial boilers, fire and burglar alarms, or sprinklers? YES NO K. Does the insured permit work by self or others over 2 ½ stories? YES NO L. Does the insured rent or lease equipment to others? YES NO M. Does the insured engage in demolition or blasting? YES NO N. Does insured work on cable TV, antennae, or communication towers? YES NO O. Does the insured do any roofing? YES NO P. Do the insured s operations involve work by LPG, LPN or natural gas? YES NO Q. Does the insured install, remove or deal with asbestos materials? YES NO R. During the last three years has any coverage been canceled, declined or non-renewed? YES NO S. Is there any evidence of financial difficulty in the last three years? YES NO T. Does the insured do any excavation work? YES NO U. Does the insured do any spray painting? YES NO V. Does the insured do snow removal? YES NO W. Does the insured do floor waxing or wood floor refinishing? YES NO X. Does the insured permit any work by self or others who have not been EPA certified for lead based paint activities and renovation? YES NO Remarks: 4. LIABILITY COVERAGE (occurrence/aggregate): 50,000/100,000 100,000/200,000 300,000/600,000 500,000/1,000,000 1,000,000/2,000,000 not available in Suffolk, Nassau, Westchester, or Rockland County ACE-14 Class Codes (Maximum of Three) Annual Payroll (25,000 minimum applies) Annual Gross Receipts (50,000 minimum applies) Does the insured employ subcontractors or temp workers? YES (please complete section below) NO (continue to page 3) Do subcontractors or temp workers carry their own insurance and certify it? YES (please attach certificates) NO Estimated payroll for subcontractors or temp workers: Description of work done by subcontractors or temp workers: 2 Ed. 11/16
5. ADDITIONAL LIMITS Coverage Provided Additional Total Accounts Receivable 1,500 Business Credit Card, Forgery, and 1,500 Counterfeit Money Business Property while on the 3,000 Insured s Premises (Special Form, Actual Cash Value, 250 deductible, Tools and Equipment excluded) Debris Removal 1,500 Unavailable 1,500 Employee Dishonesty 1,500 Money and Securities 1,500 Property of Others in Your Care, Custody, and Control 2,500 Tools and Equipment Off Premises 1,500 Valuable Papers and Records 1,500 While Away from the Insured 1,500 Premises Signs 1,500 Medical Payments (per person/per accident) 1,000/ 25,000 Fire Legal Liability 50,000 6. OPTIONAL COVERAGES Coverage Amount of Additional Insured(s) list name, mailing address, and extent of interest Computer Coverage Contractors Tools & Equipment Equipment Rental Reimbursement Extra Expense Installation Floater Loss of Earnings limit per month, for ( 3, 4, 6 ) months (circle one) LS-6 General Liability (Extra Coverage) YES NO Miscellaneous Property Floater Surveyors Property Floater Personal Injury YES NO Ed. 11/16 3
7. BUILDING AND CONTENTS COVERAGE Please attach photo of building, if coverage is requested. Physical Address Location 1 Location 2 Building Coverage Limit Building Form SF-1 SF-2 SF-3 SF-1 SF-2 SF-3 Business Personal Property Limit (does not include tools) Business Personal Property Form SF-1 SF-4 SF-1 SF-4 Construction Frame Masonry Frame Masonry Building Type Office Shop/Storage Office Shop/Storage Area (sq. ft.) Year Built Protection Class Date building purchased Purchase price Valuation Method Renovations (year) Highly Protected Protected Semi-protected Appraisal Square Foot Area Other: Wiring Plumbing Roof Heating Highly Protected Protected Semi-protected Appraisal Square Foot Area Other: Wiring Plumbing Roof Heating Is any portion of the building vacant? Are mortgage payments overdue by two months or more? During the last five years, has anyone with a financial interest in the building: Been convicted of arson, fraud or other crime? Had a fire loss of 1,000 or more? Remarks on any "Yes" answers: 4 Ed. 11/16
8. RATING WORKSHEET Package Charge 75 General Liability x (payroll per thousand) (rate) Products/Completed Ops x (receipts per thousand) (rate) Optional Coverages Total Premium* Fire Fee (75+ building premium + business personal property premium + loss of earnings premium) x.00625 *Minimum down payment: Zone 1 (All of state except counties listed below in Zone 2) 250 with products/completed ops, 200 without products/completed ops, or 25% of total premium + fire fee + 6 installment fee, if higher Zone 2 (Suffolk, Nassau, Westchester, and Rockland Counties) 350 with products/completed ops, 300 without products/completed ops, or 25% of total premium + fire fee + 6 installment fee, if higher SIGNATURES ARE REQUIRED TO BIND COVERAGE Notice of insurance information practices personal information about you, including information from a credit report, may be collected from persons other than you in connection with this application and subsequent renewals. Such information as well as other personal and privileged information collected by us or our agents may in certain circumstances be disclosed to third parties without your authorization. You have the right to review your personal information in our files and can request correction of any inaccuracies. A more detailed description of your rights and our practices regarding such information is available upon request. Any person who knowingly and with intent to defraud any insurance company or another 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 the person to criminal and [NY: substantial] civil penalties. (Not applicable in CO, HI, NE, OH, OK, OR, or VT; in DC, LA ME, TN, VA and WA insurance benefits may also be denied.) Producer s Signature Title Date Applicant s Signature Title Date Ed. 11/16 5