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

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

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  • 28 check-boxes
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C‐APP025‐0815 Page1of3
COLONY INSURANCE COMPANY – COLONY SPECIALTY INSURANCE COMPANY
PELEUS INSURANCE COMPANY
CONTRACT DIVISION - LANDOWNERS and REAL ESTATE DEVELOPMENT - 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:
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
CONTRACTS
Written contracts are always used with third parties. If not, explain:
LOSS HISTORY / EVICTIONS / VIOLATIONS
Three years of loss history information on ACORD application or attached to this application
EXPOSURES / OPERATIONS / CONTROLS
Final use will be residential
Final use will be commercial
Final use will be industrial
Insured is acting as their own general contractor
Insured is using a licensed general contractor that is insured elsewhere and provides additional insured status to
applicant
C‐APP025‐0815 Page2of3
LANDOWNERS and REAL ESTATE DEVELOPMENT - SUPPLEMENTAL APPLICATION
SUBCONTRACTORS
Uninsured subcontractors are not acceptable.
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
Hold Harmless and Indemnification Agreements – Required from subcontractors
Limits of Liability - Subcontractors are required to carry limits equal or above your own
Workers Compensation (if applicable) – Subcontractors required to have their own WC
EMPLOYEES
Total Number of Employees (include leased employees): __________
PROJECT COST
Estimated project cost: $ __________________________
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
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 and U523
Property Coverage Enhancement:
Bronze – U777C Silver – U777B or Gold-U777A
Signs (Outdoor) 0 Co1449
Water Back Up and Sump Overflow – U548
C‐APP025‐0815 Page3of3
LANDOWNERS and REAL ESTATE DEVELOPMENT - 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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COLONY INSURANCE COMPANY COLONY SPECIALTY INSURANCE COMPANY PELEUS (Strickland Insurance Brokers)

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Completed 17 July 2021

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