CAPP0170815 Page1of4
COLONY INSURANCE COMPANY – COLONY SPECIALTY INSURANCE COMPANY
PELEUS INSURANCE COMPANY
CONTRACT DIVISION – GARBAGE AND RECYCLING - 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)
Incineration facilities
Hazardous waste, industrial chemical waste, or medical waste exposures
Landfill or refuse dump management and/or ownership
SUBMIT TO BROKERAGE
Antifreeze disposal and/or recycling
Battery disposal and/or recycling
Foundry exposures
Junkyard dealers
Metal processing
Salvage operations
Scrap metal dealers
Smelting exposures
Waste oil collection
YEARS IN BUSINESS / EXPERIENCE
_____ Years in business under the ‘Named Insured’ indicated on this application
_____ Years’ experience in the operations indicated within this application Attach resume(s) if available.
Applicant had an insurance policy cancelled or non-renewed in past 3 years
(Missouri Applicants - Do not answer this question)
Applicant in receivership
Bankruptcy (Chapter 7, 11 or 13) has been filed in past 5 years
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GARBAGE AND RECYCLING - SUPPLEMENTAL APPLICATION
LICENSING
Licensed License Number: ________________________________ Year License Issued: ___________
CONTRACTS
Written contracts are always used with third parties. If not, explain: ___________________________________
LOSS HISTORY
Three years of loss history information on ACORD application or attached to this application
EXPOSURES / OPERATIONS / CONTROLS
States where work is anticipated during the policy term:
Details regarding applicants operations:
Auto coverage is carried by the insured with limits of $ __________________
Drop off recycled items by customers is allowed on insured’s premises
Fence surrounds property
Night lighting provided for premises including yard areas
Statues at Local, State or Federal level apply to facility and insured is in full compliance
SUBCONTRACTORS
Uninsured subcontractors are not acceptable. Exceptions allowed in Texas subject to Company guidelines.
Describe type of work performed by subcontractors:
Risk Transfer – Subcontractors:
A.I.A. Standard is followed when establishing contracts with 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.
Hold Harmless and Indemnification Agreements – required from subcontractors
Job to Job - same set(s) of subcontractors usually used
Limits of Liability - subcontractors are required to carry limits equal or above your own
Uninsured Subcontractors – sometimes used – Explain:
Workers Compensation (if applicable) – subcontractors required to have their own WC
EMPLOYEES
Total Number of Employees (include leased employees): __________
Describe type of work performed by employees:
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GARBAGE and RECYCLING - SUPPLEMENTAL APPLICATION
PAYROLLS / COSTS
All Owner Payroll (Cap at $16,000 per Owner)
$
All Employee Payroll (if any)
$
All Leased Employee Payroll (if any)
$
Cost of Insured Subs (if any)
$
RECEIPTS
Receipts from all operations
$
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
Medical Expense Limit of $10,000 rather than $5,000
Stop Gap Liability – U066
Storage Tank Pollution Liability - For all appointed Argo Pro (Environmental) agents, Storage Tank Pollution
Liability Coverage is available. Ask your agent for a complete application for Storage Tank Pollution Liability
Insurance if this coverage is needed. Forward all applications to: env@colonyins.com
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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GARBAGE and RECYCLING - 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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