Fillable CONTRACTORS SUPPLEMENTAL APPLICATION (Philadelphia Insurance Companies)

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CONTRACTORS SUPPLEMENTAL APPLICATION (Philadelphia Insurance Companies)

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CONTRACTORS SUPPLEMENTAL APPLICATION
Applicant Name:
Website: www.
Risk Management Contact:
Risk Management’s Phone:
Risk Management Email:
SECTION I – GENERAL INFORMATION
1.
Years in business under current name:
2.
Provide other names which you have conducted business:
3.
State(s) in which you will do or have done business:
4.
Any operations in New York state?
Yes
If yes, % in New York City, Long Island, and Westchester County % in remainder of the state.
5.
Percentage of your work: (MUST TOTAL 100%)
a. New construction: % Remodeling: % Repair: % Demolition: %
b. Commercial: % Residential: % Industrial: % Institutional: %
6.
Exposures Note: Costs to include both costs of sub-contracted labor and materials.
PAYROLL
SUB-CONTRACTOR COSTS
GROSS RECEIPTS
Next 12 Months
$
$
$
1
st
Prior Year
$
$
$
2
nd
Prior Year
$
$
$
3
rd
Prior Year
$
$
$
4
th
Prior Year
$
$
$
SECTION II – OPERATIONS
1.
Any work in the past using Exterior Insulation and finishing Systems (EIFS)?
Yes
No
2.
Any current or future plans to work on hillsides, in landfills, or areas subject to subsidence?
Yes
No
3.
Any work over three stories in height from grade (other than interior work)?
Yes
No
If yes, maximum number of stories: If yes, percentage of total work: %
4.
Does Applicant or Applicant’s sub-contractors perform any work below grade?
Yes
No
If yes, please describe:
If yes, maximum depth: feet If yes, percentage of total work: %
5.
Any past, current, or planned involvement in
a.
Blasting activities?
Yes
No
b.
Building demolition?
Yes
No
c.
Removal/remediation of lead, asbestos, radon, mold, PCBs or other hazardous materials?
Yes
No
d.
Use of scaffolding?
Yes
No
e.
Removal or work on fuel tanks or pipelines?
Yes
No
f.
Shoring, underpinning, cofferdam or caisson work?
Yes
No
6.
Does the Applicant own or lease any heavy equipment?
Own
Lease
Both
Never Use
7.
If the Applicant uses sub-contractors, complete the following:
Types of sub-contractors used:
a.
Does the Applicant always collect certificates of insurance from sub-contractors?
Yes
No
What minimum General Liability limit is required: $
b.
Does the Applicant obtain a standard written agreement from all sub-contractors?
Yes
No
c.
Does each sub-contractor hold the Applicant harmless?
Yes
No
d.
Does each sub-contractor give you an indemnification agreement?
Yes
No
e.
Does each sub-contractor agree to add the Applicant as an Additional Insured?
Yes
No
SECTION III – CLAIMS INFORMATION
1.
Is the Applicant aware of any circumstance, incident or accusation arising out of its operations
performed by you or your sub-contractors which may give rise to a claim?
Yes
No
2.
Has the Applicant had any construction defect claims in the past five (5) years?
Yes
No
Contractors Supplemental Application
Page 1 of 3
© 2019 Philadelphia Consolidated Holding Corp.
08/2019
Clear Application
Print Application
FRAUD STATEMENT AND SIGNATURE SECTIONS
The Undersigned states that he/she is an authorized representative of the Applicant and declares to the best of his/her knowledge and belief
and after reasonable inquiry, that the statements set forth in this Application (and any attachments submitted with this Application) are true
and complete and may be relied upon by Company * in quoting and issuing the policy. If any of the information in this Application changes
prior to the effective date of the policy, the Applicant will notify the Company of such changes and the Company may modify or withdraw the
quote or binder.
The signing of this Application does not bind the Company to offer, or the Applicant to purchase the policy.
*Company refers collectively to Philadelphia Indemnity Insurance Company and Tokio Marine Specialty Insurance Company
VIRGINIA APPLICANT: READ YOUR POLICY. THE POLICY OF INSURANCE FOR WHICH THIS APPLICATION IS BEING MADE, IF ISSUED,
MAY BE CANCELLED WITHOUT CAUSE AT THE OPTION OF THE INSURER AT ANY TIME IN THE FIRST 60 DAYS DURING WHICH IT IS IN
EFFECT AND AT ANY TIME THEREAFTER FOR REASONS STATED IN THE POLICY.
FRAUD NOTICE STATEMENTS
ANY PERSON WHO KNOW
INGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE
CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL
THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THAT PERSON TO CRIMINAL AND CIVIL PENALTIES (IN OREGON,
THE AFOREMENTIONED ACTIONS MAY CONSTITUTE A FRAUDULENT INSURANCE ACT WHICH MAY BE A CRIME AND MAY SUBJECT THE PERSON TO
PENALTIES). (IN NEW YORK, THE CIVIL PENALTY IS NOT TO EXCEED FIVE THOUSAND DOLLARS ($5,000) AND THE STATED VALUE OF THE CLAIM FOR EACH
SUCH VIOLATION). (NOT APPLICABLE IN AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN, NM, OK, PA, RI, TN, VA, VT, WA AND WV).
APPLICABLE IN AL, AR, AZ, DC, LA, MD, NM, RI AND WV: ANY PERSON WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS A FALSE OR FRAUDULENT CLAIM
FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE
IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES OR CONFINEMENT IN PRISON.
APPLICABLE IN COLORADO: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN INSURANCE
COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES, DENIAL OF
INSURANCE AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO KNOWINGLY PROVIDES FALSE, INCOMPLETE,
OR MISLEADING FACTS OR INFORMATION TO A POLICYHOLDER OR CLAIMANT FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE
POLICYHOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM INSURANCE PROCEEDS SHALL BE REPORTED TO THE
COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY AGENCIES.
APPLICABLE IN FL
ORIDA AND OKLAHOMA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A
STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A FELONY (IN FL, A
PERSON IS GUILTY OF A FELONY OF THE THIRD DEGREE).
APPLICABLE IN KANSAS: AN ACT COMMITTED BY ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE PRESENTED
OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, PURPORTED INSURER, BROKER OR ANY AGENT
THEREOF, ANY WRITTEN, ELECTRONIC, ELECTRONIC IMPULSE, FACSIMILE, MAGNETIC, ORAL, OR TELEPHONIC COMMUNICATION OR STATEMENT AS PART
OF, OR IN SUPPORT OF, AN APPLICATION FOR THE ISSUANCE OF, OR THE RATING OF AN INSURANCE POLICY FOR PERSONAL OR COMMERCIAL
INSURANCE, OR A CLAIM FOR PAYMENT OR OTHER BENEFIT PURSUANT TO AN INSURANCE POLICY FOR COMMERCIAL OR PERSONAL INSURANCE WHICH
SUCH PERSON KNOWS TO CONTAIN MATERIALLY FALSE INFORMATION CONCERNING ANY FACT MATERIAL THERETO; OR CONCEALS, FOR THE PURPOSE
OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO.
APPLICABLE IN KENTUCKY: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSONS FILES AN
APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION
CONCERNING ANY MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.
APPLICABLE IN MAINE, TENNESSEE, VIRGINIA AND WASHINGTON: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING
INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES OR A
DENIAL OF INSURANCE BENEFITS.
APPLICABLE IN PENNSYLVANIA: 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 COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS
SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.
APPLICABLE IN NEW YORK: 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, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SHALL BE
SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATE VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.
NAME (PLEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT
, CHAIRMAN, CEO OR EXECUTIVE DIRECTOR)
__________________
__________________________________
SIGNATURE
DATE
SECTION TO BE COMPLETED BY THE PRODUCER/BROKER/AGENT
Producer
Agency
Address (Street, Ci
ty, State, Zip)
Resident or Non-Resid
ent Surplus Lines Licensee Information for Applicant’s State of Domicile
SL License State:
SL License No.:
Agency Taxpayer ID:
Contractors Supplemental Application
Page 2 of 3
© 2019 Philadelphia Consolidated Holding Corp.
08/2019
Clear Application
Print Application
NOTICE
1. THE INSURANCE POLICY THAT YOU ARE APPLYING TO PURCHASE IS BEING ISSUED BY AN
INSURER THAT IS NOT LICENSED BY THE STATE OF CALIFORNIA. THESE COMPANIES ARE
CALLED “NONADMITTED” OR “SURPLUS LINE” INSURERS.
2. THE INSURE
R IS NOT SUBJECT TO THE FINANCIAL SOLVENCY REGULATION AND ENFORCEMENT
THAT APPLY TO CALIFORNIA LICENSED INSURERS.
3. THE INSURER DOES NOT PARTICIPATE IN ANY OF THE INSURANCE GUARANTEE FUNDS
CREATED BY CALIFORNIA LAW. THEREFORE, THESE FUNDS WILL NOT PAY YOUR CLAIMS OR
PROTECT YOUR ASSETS IF THE INSURER BECOMES INSOLVENT AND IS UNABLE TO MAKE
PAYMENTS AS PROMISED.
4. CALIFORNIA M
AINTAINS A LIST OF ELIGIBLE SURPLUS LINE INSURERS APPROVED BY THE
INSURANCE COMMISSIONER. ASK YOUR AGENT OR BROKER IF THE INSURER IS ON THAT LIST,
OR VIEW THAT LIST AT THE INTERNET WEB SITE OF THE CALIFORNIA DEPARTMENT OF
INSURANCE: www.insurance.ca.gov.
5. FOR ADDITIONA
L INFORMATION ABOUT THE INSURER YOU SHOULD ASK QUESTIONS OF YOUR
INSURANCE AGENT, BROKER, OR “SURPLUS LINE” BROKER OR CONTACT THE CALIFORNIA
DEPARTMENT OF INSURANCE, AT THE FOLLOWING TOLL-FREE TELEPHONE NUMBER: 1-800-927-
4357.
6. IF YOU, AS
THE APPLICANT, REQUIRED THAT THE INSURANCE POLICY YOU HAVE PURCHASED
BE BOUND IMMEDIATELY, EITHER BECAUSE EXISTING COVERAGE WAS GOING TO LAPSE WITHIN
TWO BUSINESS DAYS OR BECAUSE YOU WERE REQUIRED TO HAVE COVERAGE WITHIN TWO
BUSINESS DAYS, AND YOU DID NOT RECEIVE THIS DISCLOSURE FORM AND A REQUEST FOR
YOUR SIGNATURE UNTIL AFTER COVERAGE BECAME EFFECTIVE, YOU HAVE THE RIGHT TO
CANCEL THIS POLICY WITHIN FIVE DAYS OF RECEIVING THIS DISCLOSURE. IF YOU CANCEL
COVERAGE, THE PREMIUM WILL BE PRORATED AND ANY BROKER’S FEE CHARGED FOR THIS
INSURANCE WILL BE RETURNED TO YOU.
Insured: _________________________________________ Date:
Contractors Supplemental Application
Page 3 of 3
© 2019 Philadelphia Consolidated Holding Corp.
08/2019
Clear Application
Print Application
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Completed 11 February 2021

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