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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The COLONY INSURANCE COMPANY COLONY SPECIALTY INSURANCE COMPANY PELEUS (Strickland Insurance Brokers) form is 3 pages long and contains:

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  • 34 check-boxes
  • 37 other fields

Country of origin: US
File type: PDF

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C‐APP020‐0815 Page1of3
COLONY INSURANCE COMPANY – COLONY SPECIALTY INSURANCE COMPANY
PELEUS INSURANCE COMPANY
CONTRACT DIVISION - HANDYPERSON - 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
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
OPERATIONS / EXPOSURES
States where work is anticipated during the policy term:
You work in the capacity of a General Contractor ____% of the time, and/or Subcontractor ____ % of the time
Commercial / Industrial Work – New-Ground-Up Construction %
Commercial / Industrial Work – Remodeling (including additions), Repair, Service %
Residential Work – New-Ground-Up Construction %
Residential Work - Remodeling (including additions), Repair, Service %
Total of above percentages must equal 100% 100%
C‐APP020‐0815 Page2of3
HANDYPERSON - SUPPLEMENTAL APPLICATION
EXPOSURES (check only those that apply to your operations)
Above Grade work exceeds 20 feet. _____ Maximum height in feet _____ % of work above 20 feet
Below grade work exceeds 3 feet _____ Maximum depth in feet _____ % of work below 3 feet
LPG work exceeds 10% of annual receipts Actual percentage is: _____ %
Multi-family (apt, condo, co-op, townhome, tract home) exposures. Percentage of annual receipts: _________ %
Rental of Mobile Equipment with or without operators to third parties (describe):
Roofing (If payroll exceeds $7500 for roofing a roofing supplemental application required)
Vanish, Lacquer, Paint, Glue-Controls in place including proper disposal of rags (spontaneous combustion)
SUBCONTRACTORS
If the insured has subcontractor exposures they are not eligible to be classified, underwritten, rated and issued as
a ‘Handyperson’ account. Re-classification will be required.
EMPLOYEES
Generally handypersons do not have employees. If you have employees advise how many and what trades they
perform:
PAYROLLS / COSTS
All Owner Payroll (Cap at $16,000 per Owner)
$
All Employee Payroll (if any)
$
All Leased Employee Payroll (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‐APP020‐0815 Page3of3
HANDYPERSON - SUPPLEMENTAL APPLICATION
OVERAGE 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 Theft (i.e. Recovery) – U651
Medical Expense Limit of $10,000 rather than $5,000
Overspray Coverage Limitation – U679
Pollution Exclusion – Limited Exception for Short-Term Event – U680
Professional Extension – Contractors Professional Liability Coverage Limitation – U146
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 & 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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