Fillable DEMOLITION CONTRACTORS (ANNUAL POLICY) GENERAL LIABILITY APPLICATION (Colonial General Insurance Agency, Inc)

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DEMOLITION CONTRACTORS (ANNUAL POLICY) GENERAL LIABILITY APPLICATION (Colonial General Insurance Agency, Inc)

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GL-APP-82s (9-17) Page 1 of 8
DEMOLITION CONTRACTORS (ANNUAL POLICY)
GENERAL LIABILITY APPLICATION
Applicant’s Name:
Mailing Address:
Location Address:
Agency Name:
Agent No.:
Address:
E-mail:
Phone No.:
PROPOSED EFFECTIVE DATE: From To 12:01 A.M., Standard Time at the address of the Applicant
ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE” (N/A)
Applicant is: Individual Corporation Partnership Joint Venture
Limited Liability Company Other (Specify):
Website Address:
E-mail Address: Phone Number:
Inspection Contact:
E-mail Address: Phone Number:
Limits Of Liability & Deductible Requested:
General Aggregate (other than Products/Completed Operations) $
Products & Completed Operations Aggregate $
Personal & Advertising Injury (any one person or organization) $
Each Occurrence $
Damage To Premises Rented To You (any one premise) $
Medical Expense (any one person) $
Other Coverage, Restrictions, and/or Endorsements:
$
Deductible
$
1. Number of years in business: Years in demolition business:
2. Does applicant use a standard written contract? (If yes, provide a copy.)............................................ Yes No
GL-APP-82s (9-17) Page 2 of 8
3. Is applicant a subsidiary of another entity? ........................................................................................... Yes No
If yes, provide details:
4. Does applicant have any subsidiaries or related entities not listed above? ...................................... Yes No
If yes, provide details:
5. Does work the applicant performs require licensing? .......................................................................... Yes No
If yes, provide license numbers:
6. Is applicant a member of any demolition industry association? ......................................................... Yes No
If yes, provide name of association:
7. Annual payroll from demolition operations (excluding office and clerical): ........................................... $
8. Annual sales received from rental of cranes or other contractors equipment to others:
a. With operators: ...................................................................................................................................... $
b. Without operators: ................................................................................................................................. $
9. Indicate type of buildings/structures to be demolished with estimated percentage of total projects during the
next twelve (12) months:
Demolition Operations
For Buildings:
Indicate if
operations
performed
during the
past three
years
Indicate
estimated
percentage of
total projects
expected for
the next
twelve (12)
months
Demolition Operations
For Other than
Buildings:
Indicate if
operations
performed
during the
past three
years
Indicate
estimated
percentage of
total projects
expected for
the next
twelve (12)
months
Apartment Buildings % Amusement Rides %
Barns % Bridges %
Hospitals %
Chimney, Smoke Stacks,
Cooling Towers
%
Industrial Plants %
Concrete/ Rock
Breaking Work
%
Manufacturing Plants % Dams/ Levees %
Office Buildings %
Fences and/or Retaining
Walls
%
One- to Four-Family
Dwellings
%
Grain Elevators, Silos,
Grain Bins
%
Parking Structures %
Land Clearing/Tree
Removal
%
Retail Stores % Parking Lots %
Schools %
Power Transmission or
Microwave Towers
%
Small Storage Sheds/
Outbuildings
%
Railroad and/or Elevated
Tracks
%
Sport Stadiums % Streets or Roads %
Warehouses % Tanks—Above Ground %
Other: (Describe) % Tanks—Below Ground %
% Other: (Describe)
%
% %
GL-APP-82s (9-17) Page 3 of 8
10. Provide breakdown of demolition projects with estimated percentage of total projects expected during the
next twelve (12) months:
Demolition Operations Percentage Demolition Operations Percentage
Scope of Demolition Operations: Height of Buildings/Structures:
Entire Building
%
1 to 3 stories (up to 50 feet) %
Partial Building % Over 3 stories (over 50 feet) %
Interior Strip-out (Structural) % Occupancy of Buildings/Structures:
Interior Strip-out (Non-Structural) % Unoccupied %
Debris Removal only % Partially Occupied %
Machinery or Equipment removal % Location of Demolition Projects
Other: (Describe) % Urban %
% Suburban %
% Rural %
% Off-Shore %
11. Schedule Of Hazards:
Loc.
No.
Classification Description
Class.
Code
Exposure
Premium Basis
(s) Gross Sales
(p) Payroll
(a) Area
(c) Total Cost
(t) Other
12. Has applicant ever been fined, or cited for performing unsafe work? ................................................ Yes No
If yes, explain:
1
3. Describe applicant’s two largest jobs within the past three years, including size of building/structure (number
of stories), method of demolition and job cost:
14. Exposure to other buildings/structures and estimated percentage of total projects during the next twelve (12)
months:
a. Free standing buildings/structures (no abutting walls or shared common/party walls or foundations): %
b. Buildings/structures with abutting walls or shared common/party walls or foundations: ..................... %
c. Are shared walls or foundations shored up, as needed, before demolition begins? ............................ Yes No
d. Are the conditions of nearby structures documented before demolition begins? ................................. Yes No
e. Are procedures in place to verify address of demolition site prior to commencing work? .................... Yes No
15. Does applicant have a formal loss control or safety program? ........................................................... Yes No
Does applicant have a risk manager and/or safety director who is responsible for safety activities? ........ Yes No
GL-APP-82s (9-17) Page 4 of 8
16. Indicate by method of demolition the estimated percentage of work to be performed during the next twelve
(12) months:
Method of Demolition Percentage
Manual work by hand or handheld tools excluding jackhammers %
Handheld jackhammers %
Mechanical equipment (excluding cranes) such as, extended excavators, bull dozers, etc. %
Cranes or other equipment with wrecking ball or similar apparatus %
Cranes without wrecking ball (used for lifting of debris or equipment only) %
Explosives/blasting %
Robotic hydro-demolition %
High pressure water-jet lance %
Non-explosive demolition agents, such as, expansive grout %
Road milling machines %
Other (Describe): %
17. Debris disposal and/or salvage operations:
a. Will applicant retain salvage? ............................................................................................................... Yes No
b. Does applicant own or operate a salvage yard and/or act as a secondhand building materials
dealer? .................................................................................................................................................. Yes No
c. Does applicant own or operate a landfill or dump site? ........................................................................ Yes No
d. Does applicant own or operate a recycling facility? .............................................................................. Yes No
e. Does applicant own or operate a concrete/asphalt crushing facility? ................................................... Yes No
f. Annual sales of salvaged materials: ..................................................................................................... $
18. Utilities:
a. Are utility companies consulted prior to demolition to determine location of any underground
utilities? ................................................................................................................................................. Yes No
b. Does applicant obtain confirmation that all utilities have been turned off? ........................................... Yes No
c. Are utility lines, cables, piping protected from damage prior to beginning demolition? ........................ Yes No
19. Are job sites secured:
a. Temporary perimeter fencing? .............................................................................................................. Yes No
b. Area barricaded? ................................................................................................................................... Yes No
c. “No Trespassing” or other restrictive area warning signs? ................................................................... Yes No
d. Lighted during evening hours? .............................................................................................................. Yes No
e. Patrolled by Security Guards? .............................................................................................................. Yes No
20. Prior to demolition is building/structure checked for asbestos, lead, mold, PCB’s or other haz-
ardous materials? ...................................................................................................................................... Yes No
a. If present, is applicant’s employees responsible for removal? ............................................................. Yes No
b. If applicant’s employees are not responsible for removal, who is responsible and how does applicant confirm that
these materials have been removed prior to starting demolition?
21. Any pollution exposures? ........................................................................................................................ Yes No
If yes, advise:
GL-APP-82s (9-17) Page 5 of 8
22. Does applicant use subcontractors? ...................................................................................................... Yes No
If yes:
a. Subcontracted work cost: ...................................................................................................................... $
b. Are all subcontractors required to carry General Liability and Workers Compensation Insurance? .... Yes No
c. Are certificates of insurance obtained from all subcontractors? ........................................................... Yes No
If yes, indicate minimum limit of liability required: ................................................................................. $
d. Does applicant require all subcontractors to include the applicant as an additional interest on all
subcontractors’ policies? ....................................................................................................................... Yes No
e. Do written contracts contain hold-harmless agreements in favor of the applicant? ............................. Yes No
If no, explain when not required:
23. Does applicant own, rent, or operate cranes? ....................................................................................... Yes No
If yes:
a. Number of jobs in which cranes were used in the past year:
b. Number of cranes owned:
c. Number of crane operators which are applicant’s employees:
d. Are employed operators certified for crane operations being performed? ........................................... Yes No
e. Number of cranes rented annually from others:
(1) With operators? .............................................................................................................................. Yes No
(2) Without operators? ......................................................................................................................... Yes No
(3) If with operators, does applicant confirm operators are crane certified?........................................ Yes No
f. Any boom lengths in excess of one hundred forty (140) feet? ............................................................. Yes No
If yes, provide maximum boom length: ................................................................................................. ft.
g. Does applicant rent or provide cranes to others? ................................................................................. Yes No
If yes, provide details concerning with or without operators and for what type of operations:
24. Any employees working under:
United States Longshoremen’s and Harborworkers’ Act?........................................................................... Yes No
Jones Maritime Act? .................................................................................................................................... Yes No
If yes, what percent?............ % Provide city and state:
25. Does applicant have Workers’ Compensation coverage in force? ...................................................... Yes No
26. Additional Insured Information:
Name Address Interest
27. Does risk engage in the generation of power, other than emergency back-up power, for their
own use or sale to power companies?.................................................................................................... Yes No
If yes, describe:
GL-APP-82s (9-17) Page 6 of 8
28. During the past three years, has any company ever canceled, nonrenewed, declined or refused
similar insurance to the applicant? (not applicable in Missouri) ............................................................. Yes No
If yes, explain:
29. Does applicant have other business ventures for which coverage is not requested? ...................... Yes No
If yes, explain and advise where insured:
30. Prior Carrier Information:
Year: Year: Year: Year: Year:
Carrier
Policy No.
Coverage
Total Premium
31. Loss History:
Indicate all claims or losses (regardless of fault and whether or not insured) or occurrences that may give
rise to claims for the prior five years. Check if no losses last five years.
Date of
Loss
Description of Loss
Amount
Paid
Amount
Reserved
Claim Status
(Open or
Closed)
This application does not bind the applicant nor the company to complete the insurance, but it is agreed that the infor-
mation contained herein shall be the basis of the contract should a policy be issued.
FRAUD WARNING: 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. (Not applicable in AL, CO, DC, FL, KS, LA, ME, MD, MN, NE, NY,
OH, OK, OR, RI, TN, VA, VT or WA.)
NOTICE TO ALABAMA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to restitution fines or confinement in prison, or any combination thereof.
NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or in-
formation 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 policy holder or claimant for
the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award pay-
able from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory
Agencies.
WARNING TO DISTRICT OF COLUMBIA APPLICANTS: It is a crime to provide false or misleading information to an
insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addi-
GL-APP-82s (9-17) Page 7 of 8
tion, an insurer may deny insurance benefits if false information materially related to a claim was provided by the appli-
cant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any insur-
er files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a fel-
ony of the third degree.
NOTICE TO KANSAS APPLICANTS: Any person who, knowingly and with intent to defraud, presents, causes to be pre-
sented 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 state-
ment 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 con-
ceals, 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.
NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be sub-
ject to fines and confinement in prison.
NOTICE TO MAINE APPLICANTS: 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.
NOTICE TO MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent claim for
payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty
of a crime and may be subject to fines and confinement in prison.
NOTICE TO MINNESOTA APPLICANTS: A person who files a claim with intent to defraud or helps commit a fraud
against an insurer is guilty of a crime.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he is facilitating a fraud against
an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
NOTICE TO OKLAHOMA APPLICANTS: Any person who knowingly, and with intent to injure, defraud or deceive any
insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading infor-
mation is guilty of a felony.
NOTICE TO RHODE ISLAND APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment
of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to fines and confinement in prison.
FRAUD WARNING (APPLICABLE IN VERMONT, NEBRASKA AND OREGON): Any person who intentionally presents
a materially false statement in an application for insurance may be guilty of a criminal offense and subject to penalties un-
der state law.
FRAUD WARNING (APPLICABLE IN 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. Penal-
ties include imprisonment, fines, and denial of insurance benefits.
NEW YORK OTHER THAN AUTOMOBILE FRAUD WARNING: 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 also be subject to a civil penalty not to exceed five thousand dollars
and the stated value of the claim for each such violation.
GL-APP-82s (9-17) Page 8 of 8
APPLICANT’S STATEMENT:
I have read the above application and I declare that to the best of my knowledge and belief all of the foregoing statements
are true, and that these statements are offered as an inducement to us to issue the policy for which I am applying. (Kan-
sas: This does not constitute a warranty.)
APPLICANT’S NAME AND TITLE:
APPLICANT’S SIGNATURE: DATE:
(Must be signed by an active owner, partner or executive officer.)
PRODUCER’S SIGNATURE: DATE:
AGENT NAME: AGENT LICENSE NUMBER:
(Applicable to Florida Agents Only)
IOWA LICENSED AGENT:
(Applicable in Iowa Only)
IMPORTANT NOTICE
As part of our underwriting procedure, a routine inquiry may be made to obtain applicable information concerning
character, general reputation, personal characteristics and mode of living. Upon written request, additional information
as to the nature and scope of the report, if one is made, will be provided.
Agent Email: Preferred Method of Correspondence Email Fax Mail
Applicant Email: Preferred Method of Correspondence Email Fax Mail
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DEMOLITION CONTRACTORS (ANNUAL POLICY) GENERAL LIABILITY APPLICATION (Colonial General Insurance Agency, Inc)

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Completed 22 August 2020

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