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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  • 47 check-boxes
  • 22 other fields

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C‐APP015‐0815 Page1of3
COLONY INSURANCE COMPANY – COLONY SPECIALTY INSURANCE COMPANY
PELEUS INSURANCE COMPANY
CONTRACT DIVISION – FLEA MARKET, SWAP MEET and BAZAAR - 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)
Ammunition, guns or weapons
Amusement devices or rides on applicant’s premises
Armed security unless off-duty peace officers
Explosives, flammable liquids, LPG, petroleum products
Fireworks
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
Assault and Battery incident(s) have occurred in the past 3 years
C‐APP015‐0815 Page2of3
FLEA MARKET, SWAP MEET and BAZAAR - SUPPLEMENTAL APPLICATION
OPERATIONS / EXPOSURES / CONTROLS
Applicant
Is a vendor
Is the premises/property owner
Hours and Attendance
Seasonal operation If yes, dates of operation are between: ____________________________________
Numbers of days per week facilities are open to the public _______
Average daily attendance on weekends (if applicable) _______
Average daily attendance on weekdays (if applicable) _______
Facility(s)
Indoor Facilities
Emergency lighting provided
Exits marked, illuminated and not blocked
Outdoor Facilities
Parking:
Parking areas are paved
Night lighted (if premises open to the public after dark)
Vendor spaces: If yes, total number of vendor spaces available: _______
Vendors are independent contractors
Vendors who are independent contractors have their own insurance and provide certificates
confirming this to the insured
Vendors are spaced per local code requirements and fire department regulations
Security provided:
Security is provided by employees
Security subcontracted to third party, insured and provides additional insured status on their policy
Other exposures or operations not indicated above (describe):
SUBCONTRACTORS
Uninsured subcontractors are not acceptable.
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
Total of All Receipts - Annual
$
C‐APP015‐0815 Page3of3
FLEA MARKET, SWAP MEET and BAZAAR - SUPPLEMENTAL APPLICATION
COVERAGE OPTIONS - LIABILITY (check if you would like an optional 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
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
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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