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EMPLOYMENT AGENCIES (TEMPORARY CLERICAL OR RETAIL) APPLICATION (Colonial General Insurance Agency, Inc)

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GLS-APP-80s (9-16) Page 1 of 7
Scottsdale Insurance Company
Home Office: One Nationwide Plaza
Columbus, Ohio 43215
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
Scottsdale Indemnity Company
Home Office: One Nationwide Plaza
Columbus, Ohio 43215
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
Scottsdale Surplus Lines Insurance Company
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
EMPLOYMENT AGENCIES (TEMPORARY CLERICAL OR RETAIL) APPLICATION
Applicant’s Name:
Mailing Address:
Location Address:
Agency Name:
Agent No:
Address:
E-mail:
Phone:
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:
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. Description of operations:
Number of years in business:
Years of experience in this field:
GLS-APP-80s (9-16) Page 2 of 7
2. Does the applicant carry Workers’ Compensation? .............................................................................. Yes No
If yes, is coverage provided for temporary employees? .............................................................................. Yes No
3. Do any of the temporary employees hold professional licenses or certificates? .............................. Yes No
If yes, describe:
4. Are reference and background checks required on all temporary employees? ................................ Yes No
5. Is any assignment of temporary employees longer than six months? ................................................ Yes No
6. Does applicant lease employees to others? ........................................................................................... Yes No
7. Advise percentage of: Permanent Placement ............... % Temporary Placement ................ %
8. Estimated annual (excluding owner):
Payroll: Receipts: Subcontracted Cost:
9. Provide payroll breakdown between:
Clerical/Retail: Non-Clerical/Retail:
10. Provide payroll breakdown and percentage of operations for each of the following:
Payroll % Payroll %
Accounting/Finance/Insurance
Farm Labor
Administrative
Food Service/Restaurants
Architects/Engineers
Hospitality
Attorneys/Paralegals
IT/Software Development/Help
Desk
Banking
Janitorial Services
Bartenders/Bouncers
Machine Operators (skilled)
Biotech/Research/Science/Lab
Technicians
Machine Operators (unskilled)
Building Construction/Skilled Trade
Marketing
Clerical/Office
Modeling/Talent/Booking
Agencies
Client Care
Mortgage/Real Estate Brokers
Customer Support
Permanent Placement
Daycare/Nannies/Babysitting
Retail
Drivers/Truckers/Chauffeurs
Road Construction
Educational/Teachers
Security/Protective Services
Employee Leasing
Skilled Trade
Engineering
Other—Describe:
GLS-APP-80s (9-16) Page 3 of 7
11. Schedule of Hazards:
Loc.
No.
Classification Description
Class
Code
Exposure
Premium Bases
(s) Gross Sales
(p) Payroll
(a) Area
(c) Total Cost
(t) Other
12. Premises information:
Exposure
Amount
Requested
Coins.
%
ACV/Repl.
Cost
Cause
of Loss
Deductible
Special
Conditions
Building
Contents
Business
Interruption
Other
Mortgagee or loss payee:
Additional coverages, restrictions and endorsement
information:
Other carriers participating on risk:
1. %
2.
%
13. Do all written contracts contain hold-harmless agreements in favor of the applicant? .................... Yes No
If no, explain when not required:
14. Account history for prior five years and projected current year:
Year Payroll Subcontracted Cost Total Revenue
Current
1st Prior
2nd Prior
3rd Prior
4th Prior
5th Prior
15. Additional Insured Information:
Name Address Interest
16. 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:
GLS-APP-80s (9-16) Page 4 of 7
17. During the past three years, has any company canceled, nonrenewed, declined or refused simi-
lar insurance to the applicant? (Not applicable in Missouri) ................................................................
Yes No
If yes, explain:
18. Does applicant have other business ventures for which coverage is not requested? ...................... Yes No
If yes, explain and advise where insured:
19. Prior Carrier Information:
Year:
Year:
Year:
Year:
Year:
Carrier
Policy No.
Coverage
Total Premium $
$
$
$
$
20. 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 in the last five years
Date of
Loss
Description of Loss
Amount
Paid
Amount
Reserved
Claim Status
(Open or
Closed)
$
$
$
$
$
$
$
$
$
$
21. Attachments listed below must be included with the applicants’ submission:
a. Details of all losses in excess of ten thousand dollars ($10,000).
b. Workers’ Compensation schedule showing class codes.
22. Does applicant have the following? (If yes, attach copy.)
a. Independent contractor agreement? ..................................................................................................... Yes No
b. Client service agreement? .................................................................................................................... Yes No
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
GLS-APP-80s (9-16) Page 5 of 7
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 payable from in-
surance 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-
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 AUTOMOBILE FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance
company or other person files an application for commercial insurance or a statement of claim for any commercial or per-
sonal insurance benefits containing any materially false information, or conceals for the purpose of misleading, infor-
GLS-APP-80s (9-16) Page 6 of 7
mation
GLS-APP-80s (9-16) Page 7 of 7
concerning any fact material thereto, and any person who, in connection with such application or claim, knowingly makes
or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, damage or
conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or an insurance compa-
ny, 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 value of the subject motor vehicle or stated claim for each violation.
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.
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 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)
NAME AND PHONE NUMBER OF INDIVIDUAL TO CONTACT FOR INSPECTION/AUDIT:
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.
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Completed 22 August 2020

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