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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  • 17 check-boxes
  • 24 other fields

Country of origin: US
File type: PDF

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C‐APP030‐0815 Page1of3
COLONY INSURANCE COMPANY – COLONY SPECIALTY INSURANCE COMPANY
PELEUS INSURANCE COMPANY
CONTRACT DIVISION - OWNERS AND CONTRACTORS PROTECTIVE (OCP) - 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:
WHO IS PURCHASING THIS POLICY
Named Insured (i.e. Project Owner)
Designated Contractor on the behalf of the Project Owner (Policy will be in the Project Owner’s name)
DESIGNATED CONTRACTOR INFORMATION
Copy of Certificate required at time of binding to confirm liability and excess/umbrella coverage details
Number of Years in Business
License Number / Year Issued
Umbrella Limit
Primary GL Limits
CONTRACTS
Written contracts are being used
LOSS HISTORY / VIOLATIONS HISTORY
3 years of loss history information provided on ACORD or attached
C‐APP030‐0815 Page2of3
OWNERS AND CONTRACTORS PROTECTIVE (OCP) - SUPPLEMENTAL APPLICATION
OPERATIONS / EXPOSURES
Description of Job - (What is
being built or final use)
Job Number
Type of Trades Work Being Done
Construction Type Frame Joisted-Masonry
Non-Combustible Masonry-Non-Combustible
Modified-Fire-Resistive Fire-Resistive
Number of Stories
Estimated Start Date
Estimated End Date
SUBCONTRACTORS
No subcontractor exposures, if yes provide details:
EMPLOYEES
Describe type of work performed by employees:
PROJECT’S TOTAL COST
$
OCP LIABILITY LIMITS REQUIRED (check one)
OCP policies have only an ‘Aggregate Limit’ and an ‘Each Occurrence Limit’
$2,000,000 / $1,000,000
$1,000,000 / $1,000,000
$1,000,000 / $500,000
$500,000 / $500,000
$500,000 / $250,000
$250,000 / $250,000
C‐APP030‐0815 Page3of3
OWNERS AND CONTRACTORS PROTECTIVE (OCP) - 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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