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‐APP021‐0815 Page1of2
COLONY INSURANCE COMPANY – COLONY SPECIALTY INSURANCE COMPANY
PELEUS INSURANCE COMPANY
CONTRACT DIVISION - HARVESTERS (AGRICULTURAL) - 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:
QUOTE
New Business Renewal Expiring Policy Number: _______________________
OPERATIONS / EXPOSURES
Seasonal Year Round
State(s) the insured operates in:
Types of crops harvested:
ANNUAL RECEIPTS
$_______________ Farm Management or Consulting
$_______________ Harvesting by Hand (to include pruning)
$_______________ Harvesting by Machinery
Describe type(s) of equipment/machinery used:
Insured maintains the equipment and machinery
Insured owns equipment/machinery
Insured owns equipment/machinery
C‐APP021‐0815 Page2of2
HARVESTERS (AGRICULTURAL) - APPLICATION
ANNUAL RECEIPTS (continued)
$_______________ Spraying, Dusting, Fumigating, Pesticide or Herbicide Application
$_______________ Other (describe): _____________________________________________________________
LICENSING
Insured has all required licenses in states they operate in?
License Number(s): ________________________________________________________________________
SUBCONTRACTORS
Subcontractors used
Annual “Cost of Subs”: $ _______________
What responsibilities are given to subcontractors?
WORKERS COMPENSATION
Applicant carries workers compensation
Carrier Name: ______________________________________________________________________
Policy Term: _______________________________________________________________________
Workers Compensation Policy covers all employees in all states the insured operates? If no explain below:
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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