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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  • 35 check-boxes
  • 36 other fields

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File type: PDF

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C‐APP031‐0815 Page1of3
COLONY INSURANCE COMPANY – COLONY SPECIALTY INSURANCE COMPANY
PELEUS INSURANCE COMPANY
CONTRACT DIVISION - PEST CONTROL - 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: __________
Types of Licenses held: ________________________________________________________________________
CONTRACTS
Written contracts are always used with third parties. If not, explain:
LOSS HISTORY / VIOLATIONS HISTORY
3 years of loss history information provided
Environmental and/or agricultural violations have occurred
Prior suspensions or revocations of pesticide applicator license(s) have occurred
OPERATIONS / EXPOSURES
States where work is anticipated during the policy term:
C‐APP031‐0815 Page2of3
PEST CONTROL - SUPPLEMENTAL APPLICATION
SUBCONTRACTORS
Uninsured subcontractors are not acceptable. Exceptions are allowed in Texas subject to Company guidelines
Describe type of work performed by subcontractors:
A.I.A. Standard s 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
CHEMICALS
List here if certification/permit required: ____________________________________________________________
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
Pest Control
$
Landscaping
$
Other (describe):
$
TOTAL Receipts for 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‐APP031‐0815 Page3of3
PEST CONTROL - SUPPLEMENTAL APPLICATION
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
Landscapers – Care, Custody and Control – U682
Medical Expense Limit of $10,000 rather than $5,000
Overspray Coverage Limitation – U679
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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