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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  • 37 check-boxes
  • 20 other fields

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File type: PDF

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C‐APP042‐0815 Page1of3
COLONY INSURANCE COMPANY – COLONY SPECIALTY INSURANCE COMPANY
PELEUS INSURANCE COMPANY
CONTRACT DIVISION - TEMPORARY EMPLOYMENT AGENCIES - 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)
Babysitters, Day care workers, Nannies
Bartenders
Career counseling services
Construction Labor related work placements
Contingency agencies (defined as firms that primarily locate applicants for companies)
Drivers
Employees leased to industrial related firms
Executive search exposures
Farm labor
Heavy equipment operators
Industrial related work placements
Production equipment operators
Professional placements (i.e. accounting, dental, engineering, medical, lawyer)
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 / CONTRACTS
Applicant has all required licensing in place
Copy of insured’s standard client agreement is attached
C‐APP042‐0815 Page2of3
TEMPORARY EMPLOYMENT AGENCIES - SUPPLEMENTAL APPLICATION
LOSS HISTORY
Three years of loss history information on ACORD application or attached to this application
OPERATIONS / EXPOSURES / CONTROLS
Applicant references are checked before placement
Applicant background check is always made before placement
Provide a full description of the services offered:
Workers Compensation coverage is verified prior to placement
Maximum Length of time an employee is leased: _________ months
SUBCONTRACTORS
Uninsured subcontractors are not acceptable.
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
Annual Payroll
$
Annual Receipts
$
COVERAGE OPTIONS - LIABILITY (check if you would like a quote on any of the following)
Employee Benefit Liability – U058
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
Employment Practices Liability Insurance is NOT available for Temporary Employment Agencies
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
C‐APP042‐0815 Page3of3
TEMPORARY EMPLOYMENT AGENCIES - 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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