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

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C‐APP009‐0815 Page1of5
COLONY INSURANCE COMPANY – COLONY SPECIALTY INSURANCE COMPANY
PELEUS INSURANCE COMPANY
CONTRACT DIVISION – CUSTOM HOMEBUILDERS - 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
No known litigation related to construction defect. If “yes” please provide details on attached loss history.
OPERATIONS
States where work is anticipated during the coming policy term:
Applicant works in the capacity of General Contractor ____% of the time, and/or Subcontractor ____ %
Estimated number of custom home starts in the coming policy term: _________
Aver number of homes you build in a single development: __________ What is the maximum: __________
C‐APP009‐0815 Page2of5
CUSTOM HOMEBUILDERS - SUPPLEMENTAL APPLICATION
OPERATIONS (continued)
Residential Work – New-Ground-Up Construction %
Residential Work - Remodeling (including additions), Repair, Service %
Total of above percentages must equal 100% 100%
EXPOSURES / CONTROLS
Above Grade work exceeds 20 feet. _____ Maximum height in feet _____ % of work above 20 feet
Architectural Plans or Blueprints are drawn up by the applicant
Profession Liability Coverage is in place with a limit of $ _______________
Below grade work exceeds 36 inches _____ Maximum depth in feet _____ % of work below 3 feet
If more than 36 inches below grade an insured third party utility marking service is always used
Project security typically includes:
Fencing
Night lighting
Watchman
Bonding Insurance (providing Contract and Surety Bonds for you on behalf of your work are in place. If yes,
carrier is: ________________________________________________________________________________
Exterior Insulation and Finish Systems (EFIS) - Have performed work in the past using EFIS
Home Warranty program is provided to purchasers. If yes, attach copy of program.
Inspections (independent third party) are performs on all custom homes prior to release to purchaser
Jobsite locations have or will have exposures to:
Expansive soils
Flood zones
Hillsides or hilltops
Landfills, dumps (former sites)
Subsidence areas
Land – Real Estate Development property defined as raw land with no improvements or development such as
streets, road, sidewalks, or Utilities. If “yes”, number of acres and city/state: ____________________________
Zoned
Habitational
Retail
Commercial/Industrial
Land – Undeveloped and unimproved. If “yes”, number of acres and city/state: _________________________
Zoned
Habitational
Retail
Commercial/Industrial
Model Home(s) operated by insured If yes, location (city/state): ____________________________________
Multi-family Construction - Have been involved as a General Contractor in new-ground-up construction of
Multi-family habitational properties (i.e. apartments, co-ops, condos, townhomes or tract homes) in the past 10
years. If “yes”, specify year(s) on construction, number of units for that year, state and city. _____________
_____________________________________________________________________________________
Oversight of all projects is in place and performed by insured or insured’s employee(s)
Rental of Equipment to third parties. Describe equipment: __________________________________________
Roofing (If payroll exceeds $7500 for roofing related work a Roofing Supplemental Application is required)
Safety program – Formal safety program is in place and enforced
Scaffolding is used
Other jobsite contractors are allowed to use insured’s owned or rented scaffolding
C‐APP009‐0815 Page3of5
CUSTOM HOMEBUILDERS - SUPPLEMENTAL APPLICATION
EXPOSURES / CONTROLS (continued)
Vanish, Lacquer, Paint, Glue-Controls in place including proper disposal of rags (spontaneous combustion)
Wrap Ups – There are operations insured elsewhere by an owner controlled insurance program (OCIP) also
Referred to as “wrap up” insurance. If yes (details):
MAJOR JOBS COMPLETED WITHIN THE PAST 5 YEARS (including major work-in-progress or major planned projects)
Project Name Description of Project
Location of Project
(City and State)
Project Cost
Year Project
Completed
$
$
$
$
$
$
$
$
$
$
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.
C‐APP009‐0815 Page4of5
CUSTOM HOMEBUILDERS - SUPPLEMENTAL APPLICATION
SUBCONTRACTORS (continued)
Risk Transfer – Subcontractors (continued):
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
$
OTHER OPERATIONS
Insured has other operations or exposures other than contracting related. If “yes”, describe and advise where
these exposures are insured:
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‐APP009‐0815 Page5of5
CUSTOM HOMEBUILDERS - SUPPLEMENTAL APPLICATION
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
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
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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