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COLONY INSURANCE COMPANY COLONY SPECIALTY INSURANCE COMPANY PELEUS (Strickland Insurance Brokers)

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C‐APP016‐0815 Page1of4
COLONY INSURANCE COMPANY – COLONY SPECIALTY INSURANCE COMPANY
PELEUS INSURANCE COMPANY
CONTRACT DIVISION – FORESTRY, LOGGING AND LUMBERING - 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)
Blasting
Contractors equipment that is used for forestry, logging or lumbering
Controlled burns / Prescribed burns / Slash burning
Helicopter exposures
Firefighting assistance
Fire watches
Underwater logging
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
Trade Member of American Forest and Paper Association (AF&PA)
Trade Member of American Pulp and Paper Association (AP & PA)
Trade Member of Society of American Foresters (SAF)
Trade Member of Timber Operators Council (TOC)
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
LICENSING
Licensed License Number: ______________________________ Year License Issued: ___________
C‐APP016‐0815 Page2of4
FORESTRY, LOGGING AND LUMBERING - SUPPLEMENTAL APPLICATION
CONTRACTS
Written contracts are always used with third parties. If not, explain:
Tract(s) of land or timber are always identified in published plot plans or site surveys for all work. If no advise
what is used instead:
LOSS HISTORY
Three years of loss history information on ACORD application or attached to this application
OPERATIONS
States where work is anticipated during the policy term:
Operations Include Work in Close Proximity to:
Highways
Populated areas
Recreational lands
Power lines
Water lines
Skidding (i.e. movement of logs) Methods Include:
Over the ground
Cables (i.e. lifted by tree-top rigging)
Other (describe): __________________________________________________________________________
Forestry Operations Include:
Cruising and scouting for timber
Forestry Management
Forest road and/or trail building Forest road and/or trail maintenance
Re-forestation work
Survey work (separately classified, underwritten and rated)
Saw or planning mill operations (separately classified, underwritten and rated)
Logging and/or Lumbering Operations Include:
Clearing of land related to logging and lumbering operations (may include stump removal work)
Harvesting of lumber in: Natural forest(s) Tree farm(s)
Loading of logs into trucks or other means of transport
Logging/Lumbering road and/or trail building Logging/Lumbering road and/or trail maintenance
Survey work (must be separately classified, underwritten and rated)
Saw or planning mill operations (must be separately classified, underwritten and rated)
EXPOSURES / CONTROLS
Below grade work exceeds 36 inches but a third party utility marking service is always used in that case
Fire extinguishers are available, and they are also mounted on all heavy equipment that is in use
Fire watch is maintained to make sure equipment has cooled down prior to the end of the work day
Operations include work on ‘property of others’, but all required permits are maintained
Precautions are taken (when applicable) to prevent unauthorized access by third parties, damage to power or
water lines and to control erosion and prevent landslides
Rental of Equipment to third parties. Describe equipment:
C‐APP016‐0815 Page3of4
FORESTRY, LOGGING AND LUMBERING - 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:
A.I.A. Standards 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:
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)
$
Cost of Uninsured Subs (if any)
$
RECEIPTS
All Operations
$
DISCONTINUED OPERATIONS / DISCONTINUED NAMED INSUREDS
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:
C‐APP016‐0815 Page4of4
FORESTRY, LOGGING AND LUMBERING SUPPLEMENTAL APPLICATION
COVERAGE OPTIONS - LIABILITY (check if you would like an optional quote on any of the following)
Erroneous Cutting or Removal of Trees or Crops – U149 – (Limit of overage is $15,000)
Employee Benefit Liability – U058
Employment Practices Liability Insurance – U817 (Not available in AR, LA, MT, NM, NY, VT)
Fire Damage to Trees and Crops – U150 – (Limit of coverage is $15,000)
High Limits General Liability
Identity Recovery – i.e. Identity Theft – U651
Medical Expense Limit of $10,000 rather than $5,000
Overspray Coverage Limitation – U679
Pollution Exclusion – Limited Exception for Short-Term Event – U146
Professional Extension – Contractors Professional Liability Coverage Limitation – U146
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 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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COLONY INSURANCE COMPANY COLONY SPECIALTY INSURANCE COMPANY PELEUS (Strickland Insurance Brokers)

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Completed 17 July 2021

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