CSUP2380318 Page1of6
COLONY INSURANCE COMPANY – COLONY SPECIALTY INSURANCE COMPANY
PELEUS INSURANCE COMPANY
CONTRACT DIVISION – CONTRACTORS - SUPPLEMENTAL APPLICATION
(Complete in addition to Acord Application)
I. APPLICANT
Name
Address
II. OPERATIONS (Check or complete all that apply)
Describe Operations
Y
ears in Business
Y
ears Experience
States where work is anticipated during the policy term:
% Operations % Operations
Artisan/Subcontractor % Developer
%
E&O Coverage in place
Construction Project Manager* % General Contractor
%
Consultant* % Owner/Builder
%
Total of all Operations %
(must = 100%)
Type of Construction % New Construction % Remodeling Total % of all
Operations
Commercial/Industrial % % %
Residential % % %
Apartment % % %
Condominium/Townhome % % %
Total %
(must = 100%)
Real Estate Development Property Owned # Acres _________
_
Currently under development Yes No
Zoned: Habitational Retail Commercial/Industrial Other ____________________________
_
Vacant Land Owned # Acres ___________
_
Zoned:
Habitational Retail Commercial/Industrial Other ____________________________
_
*Project Managers and/or Consultants (classify as General Contractor if either is “Yes”)
Yes No Applicant is engaged in actual construction
Yes No Applicant hires or supervises subcontractors
Describe projects:
III. LAST THREE LARGEST JOBS
Start Date End Date Value Cost Description
$ $
$ $
$ $
IV. LICENSING
Number Type State If licensed in more than one state, attach list.
Year Issued License Active? Yes No
CSUP2380318 Page2of6
V. TRADES (Complete all that apply)
Trade Payroll Sub Costs Trade
Payroll Sub Costs
AC/Heating/Combined AC/Heating
Painting
Exterior 3 stories or less
Alarms/Alarm Systems
Exterior more than 3 stories
Appliances & Accessories
Interior
Carpentry
Interior
Shop only
NOC
Paving
Driveway-Parking-Sidewalk
Shop Only
Street or Road
Carpet/Rug/Upholstery Cleaning
Plastering or Stucco Work
Communication Equipment
Plumbing
Commercial/Industrial
Computer Service or Repair
Residential
Contractors Equip - Rented Others - w/o Operator
Prefabricated Building Erection
Debris Removal - Construction Site
Roofing
Commercial
Door/Window Assembled Millwork - Metal
Residential
Draftsmen
Septic Tank
Cleaning
Drywall or Wallboard Installation
Install–Service-Repair
Electrical Apparatus - Install-Service-Repair
Sheet Metal Work - Outside
Electrical Work - within Buildings
Siding Installation
Engineers or Architects - Consulting
Sign Erection - Install-Repair-Painting-Lettering
Excavation
Snow & Ice Removal
Executive Supervisor – Project Manager
Solar Energy Contractors
Fence Erection
Street Cleaning
Fire Extinguishers – Servicing-Refilling-Testing
Surveyors-Land - Not Engaged in Construction
Fire Suppression Systems - Install-Service-Repair
Swimming Pools
Install above ground
Floor Covering Install - Not Ceramic/Tile/Stone
Install below ground
Furniture/Fixtures - Install-Service-Repair
Service-Repair
Garbage/Ash/Refuse Collecting
Telephone/Telegraph/Cable TV Line Const.
Grading of Land
Television/Radio Receiving Set - Install-Repair
Greenhouse Erection
Tent/Canvas Goods – Erection-Removal-Repair
Guniting or Shot-Crete
Tile/Stone/Marble/Mosaic/Terrazzo - Interior
Handyperson
Tree Pruning/Dusting/Spraying/Trimming
House Furnishings Installation
Upholstering
Shop Only
Insulation Work
Mineral
On Customers Premises
Organic-Plastic - Solid State
Water Softening Equip. - Install-Service-Repair
Plastic
Water-
proofing
NOC
Irrigation or Drainage System Const.
Pressure Apparatus
Janitorial Service
Trowel - Exterior
Landscape/Gardening/Lawn Care
Trowel-Interior-Insulation work
Machinery/Equipment - Install-Service-Repair
Window Cleaning
Masonry
Wrecking - Buildings or Structures
Metal Erection/Installation
Other
Outside Surfaces Buildings &
Other Exterior Surfaces
Cleaning
Renovating
Comments:
CSUP2380318 Page3of6
VIII. SUBCONTRACTORS / EMPLOYEES
Total Number of Employees Total Number of Leased Employees
Is there any casual labor? Yes No If “Yes”, are the same individuals generally used? Yes No
Total Percentage of subcontracted work performed by: Insured Subcontractors %
Uninsured Subcontractors %
Total %
(must = 100%)
A.I.A. standards followed when establishing contracts with subcontractors Yes No
Copies of contracts and
certifcates are retained for
_____ years
Additional Insured – Status granted to you on the subcontractor’s policy Yes No
Hold Harmless and Indemnification Agreements Yes No
Same set(s) of subcontractors usually used Yes No
Limits of Liability - Subcontractors limits equal or above your own Yes No
Workers Compensation (if applicable) carried by subcontractor
Yes No
Certificates of Insurance obtained prior to subcontracted jobs
Yes No
IX. EXPOSURES
A. General Exposures (Check or complete all that apply)
Above Grade Work Maximum Height you will work Feet
Below Grade Work Maximum Depth you will work Feet
Grade/Slope Work Maximum % of Grade/Slope
Residential Work Custom Tract # of Units any one Project/Development
Maximum # Stories Maximum Square Footage
Maximum Dwelling Value $
Architectural Plans or Blueprints are drawn up by the applicant
Home Warranty Program provided to purchasers (If “checked”, attach copy of the program.)
Independent third-party inspections performed on all custom homes prior to release to purchaser
Model Home(s) operated by applicant Number of Homes
Commercial Work Maximum Square Footage
B. Jobsite Exposures (Check or complete all that apply)
Scaffolding used Yes No
Non-employees permitted to use applicant’s owned or rented scaffolding
Site Security
Fencing Night Lighting Watchman Other _____________________________________
_
VI. CONTRACTS
Written contracts are always used with customers prior to starting work Yes No
VII. GROSS SALES
Anticipated $ _____________________________
_
Second Year Prior $ ______________________________________
First Year Prior $ _____________________________
_
Third Year Prior $ ______________________________________
CSUP2380318 Page4of6
C. Do you perform or subcontract any of the following types of work? (Check or complete all that apply)
Abatement or Evironmental Work (asbestos, hazardous
materials, lead, PCAB, mercury, mold etc.)
Fire, Water and/or Disaster Restoration Work
Floor Waxing % of annual receipts
Alarm Monitoring LPG Work % of annual receipts
Blasting/Use of Explosives Mining – below surface level
Backflow/Building Sprinkler Moving of Buildings or Structures
Caisson or Cofferdam Overhead Rigging of Trusses or Lighting
Conversion of Structures to Condominiums Pile Driving
Crane Operations Performed by Direct Employees Pilings or Stilt Work
Drilling of any sort Shaft Sinking
Earthquake/Seismic Retrofitting Sewer Mains or Connections Construction
EIFS Tunneling
Equipment Rental to Third Parties Welding or Cutting - Welders Supplement required
Fenestration Services
Details:
D. Do you perform or subcontract work for any of the below location/customer types? (Check or complete all that apply)
Airports/Spaceports including hangar facilities located behind TSA controlled areas
Assisted Living, Group Homes, Halfway Houses, Hospital, Nursing Homes, Rehab Facilities, Safe Houses, Social Services,
Transitional Housing
Elaborate details of such work:
Banks or Financial Institutions
Alarm Installation
Bridges, Piers, Pilings, Stills or Wharves Public Roadways
Chemical Plants and/or Storage Public Utilities
Correctional or Detention Railroad Facilities, including Street Car Facilities
Governmental or Military Tribal Lands
Marine, Ocean Marine, Offshore (Oil Rigs, Cruise Ships) Other
Comments:
E. Air Conditioning, Heating, Combined AC/Heating Refrigeration Systems (Check all that apply)
Boiler Installation, Service or Repair GeoThermal Heating/Cooling Systems Installation, Service or Repair
Wood or Pellet Stove Installation, Service or Repair
F. Carpentry – Drywall – Stucco – Woodworking (Check or complete all that apply)
Chinese Drywall Underpinning
Shoring Up of Buildings/Structures Wheelchair Ramp related work % of annual receipts
Structural Renovations Wood or Pellet Stove Installation
Wood Truss Fabrication/Manufacturing
CSUP2380318 Page5of6
G. Concrete – Paving – Gunite/Shot-Crete – Masonry – Waterproofing (Check all that apply)
Concrete Pumpers: Exceeding 36 feet
Trailer-Mounted Systems that deliver concrete via boom assemblies
Skid Mounted and Rail Mounted Concrete Pumping
Flood Vents
Mudjacking (AKA slab jacking, concrete lifting, concrete
raising, and slab leveling)
Foundation Repair/Renovation on Existing Structures
Load Bearing or Structural Concrete Restoration Work Underpinning
H. Metal Erection (Check all that apply)
Ceiling or Wall Installation Outside Stairs or Railings Scaffolding
Decorative or Artistic Playground Equipment Shop Only
Fire Escapes Road/Highway/Freeway Guardrails Structural
Non-Structual
I. Roofing (Check or complete all that apply)
Member of National Roofing Contractors Association (NRCA)
New Repair\Remodel\Re-Roof Additions
Receipts $ $ $
Roofing Type % Total Work
Asphalt Shingles %
Built Up Roof Systems - %
Tar and Gravel
%
Application:
Hot Cold
Polymer-Modified Bitumen Sheet Membrane %
Application: Hot Cold
Clay or Concrete Tile %
Green Roof Systems (i.e. Living Plant/Landscape based) %
Metal %
Slate %
Spray Polyurethane - Foam Based %
Thermo-Plastic Membranes % Application: Hot Cold
Wood Shakes/Shingles % Treated Untreated
Total %
(must = 100%)
Maximum Slope Degrees
Jobsite
Barriers used to keep public from entering jobsite or equipment area Yes No
Extinguishers (ABC type – 15 lbs. or larger) are present at all jobsites Yes No
Fire watch maintained at jobsite for at least 30 minutes after equipment shut off or removal
Yes No
Inspection of all areas where heat work has been performed are completed prior to leaving jobsite
Yes No
Kettles/heat process equipment during use are at ground level, away from building Yes No
Roof openings left overnight are protected from elements
Yes No
CSUP2380318 Page6of6
X. DISCONTINUED OPERATIONS / DISCONTINUED NAMED INSUREDS (Check or complete all that apply)
Acted in the capacity of a General Contractor and/or Construction Project Manager on new-ground-up residential construction
(defined as apartments, condos, co-ops, homes or townhomes) in past 10 years.
Discontinued Operations for this application’s Named Insured(s) in the past 10 years.
Provide details below:
Operated under a different ‘Named Insured(s)’ in the past 10 years. Indicate the Named Insured(s) and corresponding
operations for the Named Insured(s) below:
XI. COVERAGE OPTIONS - LIABILITY All options may not be available for your operations
Employee Benefit Liability (Supplemental Application C-APP012 required)
Employment Practices Liability Insurance (Not available in AR, LA, MT, NM, NY, VT)
Cyber Suite
Locksmiths - Property Damage Extension
Overspray Coverage Limitation
Professional Extension – Contractors Professional Liability Coverage Limitation
Stop Gap Liability
FRAUD STATEMENT
A
ny 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.
THIS SUPPLEMENTAL APPLICATION IS INCORPORATED BY REFERENCE INTO THE PRIMARY APPLICATION
APPLICANT’S SIGNATURE DATE
click to sign
signature
click to edit
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