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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C‐APP018‐0815 Page1of5
COLONY INSURANCE COMPANY – COLONY SPECIALTY INSURANCE COMPANY
PELEUS INSURANCE COMPANY
CONTRACT DIVISION - GENERAL CONTRACTOR and PROJECT MANAGER - 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)
General Contracts and/or Project Managers with exposures to new-ground-up multi-family residential
(i.e. apartments, condos, co-ops, townhomes, tract homes).
Custom Single-Family Homebuilders who subcontract out most of their work are acceptable subject to
underwriting guidelines (maximum of 6 new starts per year). Requires separate application, underwriting,
rating and forms.
All of the following exposures are prohibited, even if subcontracted (check all that apply):
Airport facilities Equip.Rental to third parties Shoring or underpinning
Boring Hazardous material abatement Stadium construction
Boiler inspection Landfills Stevedoring
Bldg/Structure–raise or move Nuclear Subaqueous
Cantilevered construction Pile Driving Subways
Cofferdam or caisson work Pipelines Tank construction or removal
Dams / Levees / Reservoirs Power generating facilities Tower construction
Drilling Railroad related Tunnels
EIFS or EIFS related work Reclamation Wrap up participation
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: _________
C‐APP018‐0815 Page2of5
CONTRACTOR and PROJECT MANAGER - 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
OPERATIONS
States where work is anticipated during the policy term:
Commercial Work – New-Ground-Up Construction %
Commercial Work – Remodeling (including additions) %
Residential Work – New-Ground-Up Construction %
Residential Work - Remodeling (including additions) %
Total of above percentages must equal 100% 100%
**If any of the following are checked the Construction Project Manager exposure needs to be re-classified,
underwritten, priced and issued per the following:
Consult on or manage projects that include new residential construction (re-classify as Custom Homebuilder)
Engage in actual construction work (reclassify as an Executive Supervisor)
Hire (including authority to dismiss/fire) subcontractors (Re-classify as an Executive Supervisor)
Supervise subcontractors (reclassify as an Executive Supervisor)
Exposure % of Operations
Construction Project Manager ** %
Consultant %
Developer %
General Contractor %
Owner / Builder %
Subcontractor %
Other (Describe) %
Other (Describe) %
Other (Describe) %
EXPOSURES
Above Grade work exceeds 20 feet. _____ Maximum height in feet _____ % of work above 20 feet
Below Grade work exceeds 3 feet _____ Maximum depth in feet _____ % of work below 3 feet
Multi-family habitational related work (apts, condos, coops, townhouses, tract homes) % of operation: ______%
Rental of Mobile Equipment with or without operators to third parties. Describe:
Roofing (If payroll exceeds $7500 for roofing a roofing supplemental application required)
Vanish, Lacquer, Paint, Glue or similar finish exposures
All required equipment and procedures in place for finishing related work, including proper disposal of rags to
prevent spontaneous combustion
Additional exposures not mentioned above:
C‐APP018‐0815 Page3of5
CONTRACTOR and PROJECT MANAGER - SUPPLEMENTAL APPLICATION
SUBCONTRACTORS
Uninsured subcontractors are not acceptable. Exceptions are allowed in Texas subject to Company guidelines.
Risk Transfer – Subcontractors:
A.I.A. Standard is 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
PAYROLLS and COSTS
Class Employee
Payroll
Sub Cost Class Employee
Payroll
Sub Cost
Alarm Systems $ $ Painting $ $
Asbestos Removal $ $ Paving Driveways/ Parking $ $
Blasting $ $ Paperhanging $ $
Bridges / Elevated Roads $ $ Plastering / Stucco $ $
Carpentry $ $ Plumbing $ $
Communication Lines $ $ Power Lines $ $
Concrete $ $ Process Piping $ $
Debris Removal $ $ Roofing $ $
Demolition $ $ Seismic Retrofitting $ $
Drywall $ $ Septic Tanks $ $
Earthquake Repair $ $ Sewer $ $
Electrical $ $ Sheet Metal Work $ $
Excavation $ $ Siding $ $
Fire Damage Restoration $ $ Sprinklers $ $
Gas / Water Mains $ $ Steel / Ornamental $ $
Grading of Land $ $ Steel / Structural $ $
HVAC $ $ Street / Road $ $
Insulation $ $ Supervisory $ $
Landscaping $ $ Swimming Pools $ $
Lead Remediation $ $ Tile / Stone / Marble $ $
Masonry $ $ Waterproofing $ $
Mold/Spore Remediation $ $ Water Damage Restoration $ $
Oil or Gas Field Related
(describe):
$ $ Other (describe):
$ $
NUMBER OF EMPLOYEES
Total Number of Employees (include leased employees): __________
C‐APP018‐0815 Page4of5
CONTRACTOR and PROJECT MANAGER - SUPPLEMENTAL APPLICATION
PAYROLLS / COSTS – COMBINED TOTALS
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
$
DISCONTINUED OPERATION(S) / 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. Indicate specific
year(s) of this type of exposure, number of units for the respective year(s) and the location(s) below:
Operated under a different ‘Named Insured(s)’ in the past 10 years. Indicate the Named Insured(s) and
corresponding operations below:
Discontinued Operations for this application’s Named Insured(s) in the past 10 years. Provide details 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
Landscapers – Care, Custody and Control – U682
Medical Expense Limit of $10,000 rather than $5,000
Overspray Coverage Limitation – U679
Pollution Exclusion – Limited Exception for Short-Term Event – U680
Professional Extension – Contractors Professional Liability Coverage Limitation – U146
Property Damage Extension for Locksmiths – U082
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 a quote on any of the following)
Building Ordinance or Law (Increased Cost of Construction) – U750
Equipment Breakdown – U522 & U523
Property Coverage Enhancement (choose only one):
Bronze – U777C Silver – U777B Gold – U777C
Water Back Up and Sump Overflow – U548
C‐APP018‐0815 Page5of5
GENERAL CONTRACTOR and PROJECT MANAGER - SUPPLEMENTAL APPLICATION
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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