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

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  • 61 check-boxes
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C‐APP027‐0815 Page1of4
COLONY INSURANCE COMPANY – COLONY SPECIALTY INSURANCE COMPANY
PELEUS INSURANCE COMPANY
CONTRACT DIVISION - MANUFACTURING - 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 PRODUCTS (check all that apply to your operations)
Aerospace, airport or aviation related
Auto parts if operating type or safety related
Bridge components
Chemicals
Cosmetics
Dam, Levee or Reservoir related
Gas, fuel or oil refinery related, Petrochemical related
Grain elevator, mill or silo related
Heavy industrial equipment such as conveyors, cranes, injection molding, hydraulics, hydraulically controlled
equipment, lifting devices, packing equipment, production line equipment, presses, textile machine related
Herbal products
Infant or toddler related
Medical equipment
Penal institution related
Presses
Pressure vessels
Power plant or Utility related
Railroad related
Tobacco related
Towers or tower components
Underground mining related
Underground storage tanks
Welding equipment
C‐APP027‐0815 Page2of4
MANUFACTURING – 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
PRODUCTS
What is manufactured?
If a component for someone else’s product what is the final use of that completed product?
Check all that apply:
Product is manufactured by insured
Product is manufactured by a third party to the insured’s specifications
Product is directly imported from the country of: ________________________________
Product may be customized to customer specifications
Product instruction and warning labels are reviewed by the insured legal representative
Product is designed for use by the general public
Product is designed for use by specialized users, not the general public
Product is sold under the insured’s logo or company name
Product is sold with a serial number
Product has identification applied that makes it easy to recall products
Product may be refurbished and then resold
If yes, what product(s): ____________________________________________________________________
Product may be previously used and sold without refurbishing.
If yes, what product(s): ____________________________________________________________________
Product may be previously used and but only resold after refurbishing and retesting
If yes, what product(s): ____________________________________________________________________
Product is manufactured to standards established by ISO 9000 or ISO 9002
Product is manufactured to standard(s) of (describe):
UL LISTED
Product has electrical components that are UL listed or UL approved
C‐APP027‐0815 Page3of4
MANUFACTURING – SUPPLEMENTAL APPLICATION
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
SUBCONTRACTORS
Uninsured subcontractors are not acceptable. Exceptions allowed in Texas subject to Company guidelines.
Describe type of work performed by subcontractors:
Risk Transfer – 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.
Limits of Liability - Subcontractors are required to carry limits equal or above your own
EMPLOYEES
Total Number of Employees (include leased employees): __________
RECEIPTS
All Operations
$
DISCONTINUED PRODUCTS / DISCONTINUED NAMED INSUREDS
Discontinued Products. 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 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
Stop Gap Liability – U066
C‐APP027‐0815 Page4of4
MANUFACTURING – SUPPLEMENTAL APPLICATION
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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