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

Fill Online, Printable, Fillable, Blank COLONY INSURANCE COMPANY COLONY SPECIALTY INSURANCE COMPANY PELEUS (Strickland Insurance Brokers) Form

Use Fill to complete blank online STRICKLAND INSURANCE BROKERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

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

On average this form takes 35 minutes to complete

The COLONY INSURANCE COMPANY COLONY SPECIALTY INSURANCE COMPANY PELEUS (Strickland Insurance Brokers) form is 5 pages long and contains:

  • 2 signatures
  • 78 check-boxes
  • 96 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Strickland Insurance Brokers forms online.

BROWSE STRICKLAND INSURANCE BROKERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
C‐APP035‐0316 Page1of5
COLONY INSURANCE COMPANY – COLONY SPECIALTY INSURANCE COMPANY
PELEUS INSURANCE COMPANY
CONTRACT DIVISION - ROOFERS - 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)
All of the following exposures are prohibited, even if subcontracted
Equip.Rental to third parties
Height of exterior work exceeds 6 stories or 72 feet – Submit to Brokerage
Work locations: Assisted Living, Behind TSA secured areas, Correctional or
Detention Facilities, Hospitals,, Mining facilities, Nursing Homes, NYC’s Five
Boroughs, Offshore, Public Roadway facilities, Public Utility facilities,
Built-up roof systems using Polymer-modiifed bitumen sheet membrance
Green roof systems
Membranes that are either single-ply, thermoplastic or thermoset
Wood shakes or shingles if untreated
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?
(Missouri Applicants - Do not answer this question)
If yes, explain.
Applicant in receivership
Bankruptcy (Chapter 7, 11 or 13) has been filed in past 5 years
LICENSING / MEMBERSHIPS
Licensed License Number: ________________________________ Year License Issued: ___________
Member of National Roofing Contractors Association (i.e. NRCA)
CONTRACTS (check if applicable)
Written contracts are always used with third parties. If not, explain:
C‐APP035‐0316 Page2of5
ROOFERS - SUPPLEMENTAL APPLICATION
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:
EXPOSURES
System Type % of Total
Work
Eligible**
Asphalt Shingles %
Yes
Built Up Roof Systems - Tar and Gravel %
Yes
Built Up Roof Systems – Polymer-Modified Bitumen Sheet Membranes %
No
Clay or Concrete Tile %
Yes
Green Roof Systems (i.e. Living Plant/Landscape based) %
No
Metal - Panel roof Systems – Low Slope Applications %
Yes
Metal - Roof Systems - Steep Slope Applications
%
Yes
Slate
%
Yes
Spray Polyurethane - Foam Based %
Yes
Synthetic Coverings - NOC %
Yes
Thermo-plastic Membranes %
No
Thermo-Set Membranes %
No
Wood Shakes or Wood Shingles - Treated %
Yes
Other (Describe): % Contact Company
Other (Describe): % Contact Company
TOTAL of All Types of Roofing Work 100%
Type of Roofing Work % of
Receipts
Eligible**
Commercial – New Construction % Yes
Commercial – Repair, Remodel, or Re-roof % Yes
Industrial – New Construction or Repair %
No
Residential – Repair, Remodel, or Re-roof of Individual Dwellings % Yes
Residential – Additions onto Condos, Apartments, or Townhomes %
No
Residential – Additions onto Individual Dwellings % Yes
Residential – New Construction – Individual or Custom Dwellings only % Yes
Residential – New Construction – Tract , Condos, Apts, Townhomes %
No
Residential – Repair, Remodel, or Re-roof of Apartments % Yes
Residential – Repair, Remodel, or Re-roof of Multi-family Dwellings % Yes
Other (Describe): % Contact Company
Other (Describe): % Contact Company
TOTAL of All Types of Roofing Work 100%
**Subject to Company Guidelines
C‐APP035‐0316 Page3of5
ROOFERS - SUPPLEMENTAL APPLICATION
EXPOSURES
Above Grade work exceeds 30 feet. _____ Maximum height in feet _____ % of work above 30 feet
Multi-family habitational related work (apts, condos, coops, townhouses, tract homes) % of operation: ______%
Wood shingles (untreated)
Heat Process / Tar Kettles in use, check if any of the following apply at jobsites:
Barriers are used to keep the public from entering jobsite or heat equipment area
Extinguishers (ABC type – 15 lbs. or larger) are present at all jobsites
Fire Watch maintained at jobsite for at least 30 minutes after equipment shut off or removed
Inspection of areas where heat work has been performed are completed prior to leaving jobsite
Kettles/heat process equipment during use are at ground level, away from building
Additional operations or exposures not mentioned above:
PRIOR PROJECTS
Please list major projects completed the past 3 years, including in-progress or planned, or attach a project list.
Project Name Roofing System Type
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. 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
EMPLOYEES
Number of Employees (include leased employees): ________
Describe type of work performed by employees:
C‐APP035‐0316 Page4of5
ROOFERS - SUPPLEMENTAL APPLICATION
PAYROLLS / COSTS
Type of Work Employee Payroll Sub-Contractor Cost
Carpentry (Other than involved directly with roofing)
$ $
Executive Supervisory
$ $
Gutter Installation, Repair, or Replacement
$ $
Insulation Work
$ $
Roofing – Commercial
$ $
Roofing – Residential
$ $
Solar Panel or other Solar Energy Work
$ $
Waterproofing work
$ $
Other (Please describe)
$ $
Other (Please describe)
$ $
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:
COVERAGE OPTIONS - LIABILITY (check if you would like an opitonal 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
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
C‐APP035‐0316 Page5of5
ROOFERS - SUPPLEMENTAL APPLICATION
FRAUD WARNING
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.
DO NOT SIGN UNTIL YOU HAVE READ THE CONTENTS OF THIS APPLICATION AND THE APPLICABLE
FRAUD WARNING(S).
I have reviewed the contents of this application and with my signature, declare that to the best of my
knowledge that all statements herein are true and no material facts have been suppressed or misstated. I am
also aware that my operation may be inspected by the Insurance Company.
SIGN AND DATE
APPLICANT’S PRINTED NAME
APPLICANT’S SIGNATURE DATE
AGENT OR BROKER’S NAME LICENSE NO.
AGENT OR BROKER’S SIGNATURE DATE
click to sign
signature
click to edit
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

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

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 17 July 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document