CAPP0080815 Page1of4
COLONY INSURANCE COMPANY – COLONY SPECIALTY INSURANCE COMPANY
PELEUS INSURANCE COMPANY
CONTRACT DIVISION – CONVENIENCE STORES - SUPPLEMENTAL APPLICATION
ACORD Application also required - Check all applicable checkboxes below
General Agent:
Date:
Insured:
Insured Mailing Address:
Insured’s Web Address:
Insured Contact Name:
Phone Number:
PROHIBITED (check all that apply to your operations)
Ammunition and/or gun sales
Auto repair
Drug Paraphernalia and Synthetic Drug sales (Legal or Illegal):
Paraphernalia:
Defined as any equipment, product or material of any kind which is primarily intended or designed
for use in manufacturing, compounding, converting, concealing, producing, processing, preparing,
injecting, ingesting, inhaling, or otherwise introducing into the human body a controlled
substance.
Examples include but are not limited to: Bongs; carburetion tubes and devices,
carburetion/smoking masks; chillums (i.e. cone-shaped marijuana/hash pipes); digital
scales; emptied out pens; freebase kits; hashish heads, or punctured metal bowls;
miniature spoons with level capacities of one-tenth cubic centimeter or less; pipes – i.e.
air-driven, carburetor, electric, ice/chiller, water; roach clips (i.e. objects used to hold
burning material such as a marijuana cigarette, that has become too small or too short to
be held in the hand); vaporizers; vials; wired cigarette papers
Synthetic drugs:
Defined as fake marijuana or other substances that are marketed as potpourri, bath salts, incense
or other household products are strictly prohibited. These are products that have labeling that
has no actual relationship to the materials inside of the packaging. They are marketed and sold
to be inhaled or consumed internally. They may be sold over-the-counter or under-the-counter.
Under-the-counter sales occur for products that have packaging that mimics either the look or the
name of street drugs. Anyone who has sold these types of products in this manner (past or
present) is ineligible for coverage.
E-cigarettes and/or vapor pipes IF they exceed 10% of total annual receipts
Firearms on premises
Fireworks sales
Hookah or Oxygen Bars
LPG tank refilling (tank exchange acceptable if kept locked in cage outside of building)
Rental of moving equipment
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CONVENIENCE STORES - SUPPLEMENTAL APPLICATION
YEARS IN BUSINESS / EXPERIENCE
_____ Years in business as the ‘Named Insured’ indicated on this application
_____ Years’ experience in the operations indicated on this application - Attach resumes if available
Has applicant had an insurance policy cancelled or non-renewed in past 3 years? If yes, explain.
(Missouri Applicants - Do not answer this question)
Applicant in receivership
Bankruptcy (Chapter 7, 11 or 13) has been filed in past 5 years
LOSS HISTORY
Three years of loss history information on ACORD application or attached to this application
OPERATIONS / EXPOSURES / CONTROLS
Building areas is 5,000 square feet or less (if not then not eligible for convenience store classification)
Construction or renovation in progress or contemplated.
Construction or renovation will be done by insured third parties who will name you as an additional
insured on their policy
Details including estimated project cost:
Hours of operation - 24 hour
Cooking:
Automatic-extinguishing system service contract and ductwork cleaning contract in place
Service and cleaning contracts for this system have at least a semi-annual frequency
Grease cooking and grease vapor producing equipment (grills, fryers or similar) protected by Automatic Fire
Extinguishing System (i.e. Ansul or similar)
Liquor:
Alcohol sales
Employees in retailing of liquor are required to have formal training
I.D. required on all alcohol sales
Safety/Security:
Central station burglar alarm
Emergency lighting
Exit signed illuminated
Guard dog on premises
SUBCONTRACTORS
Uninsured subcontractors are not acceptable. Exceptions allowed in Texas subject to Company guidelines.
Describe type of work performed by subcontractors:
Risk Transfer – Subcontractors:
Additional Insured – Status granted to you on the subcontractor’s policy
Certificates of insurance - Always obtained from a subcontractor prior to any work being done for you.
Limits of Liability - Subcontractors are required to carry limits equal or above your own
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CONVENIENCE STORES - SUPPLEMENTAL APPLICATION
EMPLOYEES
Total Number of Employees (include leased employees): __________
Describe type of work performed by employees:
RECEIPTS
Car Wash
$
Food and non-alcoholic beverages (to include all restaurant receipts)
$
Gasoline
$
Liquor
$
LPG – Tank exchange
$
Lottery tickets (count commissions from sales only)
$
Other (describe)
$
Other (describe)
$
Other (describe)
$
TOTAL $
COVERAGE OPTIONS - LIABILITY (check if you would like a quote on any of the following)
Employee Benefit Liability – U058
Employment Practices Liability Insurance – U817 (Not available in AR, LA, MT, NM, NY, VT)
High Limits General Liability
Identity Recovery – i.e. Identity Theft – U651
Liquor Liability -
Medical Expense Limit of $10,000 rather than $5,000
Stop Gap Liability – U066
COVERAGE OPTIONS - PROPERTY (check if you would like a quote on any of the following)
Building Ordinance or Law (Increased Cost of Construction) – U750
Equipment Breakdown – U522 & U523
Property Coverage Enhancement: Bronze – U777C Silver – U777B or Gold – U777A
Signs (Outdoor) – CP1440
Water Back Up and Sump Overflow – U548
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CONVENIENCE STORES - SUPPLEMENTAL APPLICATION
GENERAL FRAUD STATEMENT (Not applicable in all 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 conceals for the purpose of misleading,
information concerning any fact material thereto, may be committing a fraudulent insurance act, and may be subject to
a civil penalty or fine.
The undersigned is an authorized representative of the applicant and certifies that reasonable inquiry has been made to
questions on this application. He/She certifies:
The answers are true, correct and complete to the best of his/her knowledge.
They agree to the Privacy and Fraud provisions found in the ACORD-125 (Commercial Insurance Application)
and understand those provisions also apply to this supplemental application.
SIGN AND DATE
PRODUCER’S SIGNATURE DATE
APPLICANT’S PRINTED NAME DATE
APPLICANT’S SIGNATURE DATE
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