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:

  • 2 signatures
  • 55 check-boxes
  • 19 other fields

Country of origin: US
File type: PDF

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C‐APP043‐0815 Page1of3
COLONY INSURANCE COMPANY – COLONY SPECIALTY INSURANCE COMPANY
PELEUS INSURANCE COMPANY
CONTRACT DIVISION - VACANT BUILDING - SUPPLEMENTAL APPLICATION
ACORD Application also required - Check all applicable checkboxes below
This application is mandatory if you have construction exposures (remodel, renovation, demolition)
General Agent:
Date:
Insured:
Insured Mailing Address:
Insured’s Web Address:
Insured Contact Name:
Phone Number:
PROHIBITED (check all that apply to your operations)
Attractive nuisance exposures (mines, motorized vehicle trails, pits, quarries, swimming holes
Condemned property(s), or anticipated to be condemned
Damage to premises has not yet been repaired
Environmental cleanup or remediation sites, as well as former landfill or garbage dumps
Have not:
Boarded up buildings not actively for sale
Checked property at least twice a month
Posted property with “No Trespassing” signs
Secured premises against unauthorized entry
Historic Register Properties
Insured has lapsed on property, we require concurrent coverage to place a vacant building policy
Premises are to be converted or remodeled to be multi-family habitational property such as apartments, condos,
coops or townhomes
Prior Occupancy was related to:
Aerospace, airport facilities
Chemicals, Hazardous materials
Dams, reservoirs, levees
Grain elevators, silos
Mining or quarry operations
Petrochemical, Petroleum bulk storage, Refineries
Power Plants
Railroads
Storage tanks
C‐APP043‐0815 Page2of3
VACANT BUILDING - SUPPLEMENTAL APPLICATION
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
LOSS HISTORY
Three years of loss history information provided on ACORD application or attached to this application
EXPOSURES / CONTROLS
Vacant because of:
Foreclosure Estate settlement Bsns Discontinued Loss of tenant
Other (describe): __________________________________________________________
Vacancy period exceeds 4 years, submit for approval required. Vacant since (month/year): ________________
Property is actively up for sale
Property is actively up for lease
Property is in receivership
Utilities have been disconnected
Water pipes drained (assuming location is exposed to freezing temperatures)
CONSTRUCTION
Total Project Cost: $ ___________________
Describe Project:
Insured is acting as their on general contractor
Insured has prior construction experience, including general contracting experience
Insured is doing their own demolition (buildings scheduled for demolition can not be covered for property)
Insured is subcontracting their demolition
SUBCONTRACTORS
Uninsured Subcontractors are not acceptable.
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.
Hold harmless and Indemnification Agreements – Required from subcontractors
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
C‐APP043‐0815 Page3of3
VACANT BUILDING - SUPPLEMENTAL APPLICATION
COVERAGE OPTIONS - LIABILITY (check if you would like a quote on any of the following)
Employment Practices Liability Insurance – U817 (Not available in AR, LA, MT, NM, NY, VT)
High Limits General Liability
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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