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- C-APP033-0815 Rental - Suppl App

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C‐APP033‐0815 Page1of4
COLONY INSURANCE COMPANY – COLONY SPECIALTY INSURANCE COMPANY
PELEUS INSURANCE COMPANY
CONTRACT DIVISION – RENTALS - 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)
Rental contracts signed by persons not at least 18 years old or older
Animal rentals
Baby, Infant, Toddler – Equip, Furniture, Supplies (Children’s seats, bike trailers, jogging strollers)
Bleachers (portable type)
Boats – Any boat that is equipped with a motor. The following classes are a prohibit:
Boats Rented to Others (but canoes and rowboats are acceptable)
Boats – Motor or Sail – Rented to Others
Boats – Non-owned Over 26 Feet
Bunk beds, Loft Beds
Child, infant or toddler products to include but not limited to: jogging strollers, trailers, seats
Consignment sales (i.e. sale of used items owned by third parties)
Contractors Equipment – Prohibited in Contract, but possibly eligible in Brokerage for the following:
Contractors Equipment - Earth Moving Equipment other than Cranes, Derricks & Power Shovels – Rented to
Others with Operators
Contractors Equipment - Earth Moving Equipment other than Cranes, Derricks & Power Shovels – Rented to
Others without Operators
Contractors Equipment – Excluding Automobiles – Rented to Others with Operators
Contractors Equipment – Excluding Automobiles – Rented to Others without Operators
Contractors Equipment - Hod or Material Platform Hoists & Equipment Including Incidental Thereto – Rented
to Others with Operators
Contractors Equipment - Hod or Material Platform Hoists & Equipment Including Incidental Thereto – Rented
to Others without Operators
Contractors Equipment - Steam Boilers, Compressors, Air Pressure Tanks, Pneumatic Tools & Equipment
Incidental thereto – Rented to Others with Operators
Contractors Equipment - Steam Boilers, Compressors, Air Pressure Tanks, Pneumatic Tools & Equipment
Incidental thereto – Rented to Others without Operators
Contractors Equipment – All of the following classes are prohibited in both Binding and Brokerage:
Contractors Equipment – Cranes, Derricks, Power Shovels and Equipment Incidental Thereto – Rented to
Others with Operators
Contractors Equipment – Cranes, Derricks, Power Shovels and Equipment Incidental Thereto – Rented to
Others without Operators
Contractors Equipment – Ladders, Scaffolds, Scaffolding, Sidewalks, Bridges, Towers & Equipment Incidental
thereto – Rented to Others
Contractors Equipment – Scaffolds, Sidewalks, Bridges, Hod or Material Hoist Towers – Rented to Others –
Installation, Repair or Removal Operations Only
C‐APP033‐0815 Page2of4
RENTAL - SUPPLEMENTAL APPLICATION
PROHIBITED (continued) (check all that apply to your operations)
Costumes if rented to children
Farm Equipment
Golf-mobile sales and/or use on public roadways
Hospital, Medical or Surgical Equipment (including hospital beds or wheel chairs), refer to Allied Medical
Ice skates, rollerblades, skates, skis and snowboards in states east of the Mississippi River (excluding IL and WI)
Inflatables:
Bounces, Bounce Houses, Cold Air Inflatables, Giant Balls, Hot Air Balloons, Inner Tubes, Moon Bounces
Long Term Rentals (over six months), submit to Brokerage
Medical Equipment – submit to Allied Medical
Property while leased, loaned or rented to others (property may be covered while actually on insured’s premises
written as BPP, no Inland Marine Coverage)
Rent-to-Own Stores
Scaffolding and/or Lifting Devices
Tents or Canopies whose individual area exceeds 7500 square feet, multi-story tents, semi-permanent tents.
Property coverage for Tents or Canopies is not available.
Transport Related:
ATVs, Jet skis, Snowmobiles and similar motorized recreational equipment
Auto, Truck, or Motorized Vehicle
Carriages, pedicabs and rickshaws or similar non-motorized transport
Chairs (motorized), wheel chairs, submit to Allied Medical
Mopeds, Motorcycles, Segways, Scooters and any other type of motorized transport device
Moving equipment such as trucks, vans, trailers, hitches, towing equipment
Roller Chairs (used on boardwalks)
Trailers – Camper, Travel and/or Utility
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
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:
Contracts for rental always include a ‘Hold Harmless’ clause, and waiver/release clause
Installation or setup provided by applicant. If “yes” describe:
Safety equipment (if applicable is always made available to all customers)
Safety/Security:
Central station burglar alarm Guard dog on premises
C‐APP033‐0815 Page3of4
RENTAL - SUPPLEMENTAL APPLICATION
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
EMPLOYEES
Total Number of Employees (include leased employees): __________
RENTAL INCLUDES (submit required if not listed below, do not submit items on prohibit list above)
Audio/Visual Equipment
Beach chair / umbrella
Bicycles
Boats – under 26 ft, without motors
Canoes without motors
Casino Games
China, Glasses, Linens, Utensils
Costumes - Adult
Floor or Carpet Equipment
Formal wear
Furniture - Chairs or tables
Furniture – Household type
Furniture – Office type
Generators - Small
Golf-mobiles (no public road use)
Household Type Appliances
Kayaks
Lawn / Garden Equipment
Lawnmowers
Lighting Equipment (not higher than 24 ft)
Musical Equipment
Office Equipment
Paddleboats / Paddleboards
Paint / wall Paper Equipment
Part Goods and Decorations
Rowboats
Skates / Rollerblades
Skis / Snowboards
Small Pneumatic Equipment
Stages (any back display or overhang must not exceed 24 feet above ground)
Tents or Canopies
Total number of tents or canopies available for rent: _____
Maximum square footage of single tent/canopy: ________ sq ft
Toilets / Washrooms / Washroom Trailers
Tools – Small Hand tools
Tools – Power Tools
Water Softening Equipment
C‐APP033‐0815 Page4of4
RENTAL - SUPPLEMENTAL APPLICATION
RECEIPTS
Total annual receipts: $ ______________
COVERAGE OPTIONS - LIABILITY (check if you would like an optional 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
COVERAGE OPTIONS - PROPERTY (check if you would like an optional 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
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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Completed 18 July 2020

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