Fillable EXCAVATORS AND GRADING OF LAND SUPPLEMENTAL APPLICATION (RT Specialty)

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EXCAVATORS AND GRADING OF LAND SUPPLEMENTAL APPLICATION (RT Specialty)

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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
1-800-423-7675 • Fax (480) 483-6752
www.scottsdaleins.com
EXCAVATORS AND GRADING OF LAND SUPPLEMENTAL APPLICATION
(Complete in addition to ACORD General Liability Application)
Name of Applicant:
Website Address:
E-mail Address: Phone Number:
Location Address:
1. Description of operation:
How long have you been in business? .......... Full-time Part-time
Years of experience in this field?
2.
Employee Data Number Annual Payroll
Owner(s) only
$
Full-time
$
Part-time
$
Leased or Subcontracted
Number
Annual Cost
Leased Employees
$
Independent Contractors
$
3. Projected annual sales: $
4. Does applicant or their subcontractors use explosives? ..................................................................... Yes No
(If applicable, complete Blasting Contractors Supplemental Application, GLS-APP-67s.)
5. Does applicant make a thorough study of the subsurface, including identification of existing
utility pipes and lines, prior to any digging? ..........................................................................................
Yes No
6. Is all self-propelled mobile equipment transported to job sites by trailer? ........................................ Yes No
7. If shoring is required on a job, does applicant use OSHA approved equipment and techniques? Yes No
8. Does applicant stabilize soil with lime or concrete? ............................................................................. Yes No
9. Does applicant perform underpinning operations? ............................................................................... Yes No
GLS-APP-12s (10-13) Page 1 of 4
Submit Here
10. Does applicant have sufficient signs, barricades and fences to keep non-employees at a safe
distance from job sites and equipment?.................................................................................................
Yes No
11. Equipment is: ............................................................................................................................... owned or rented
(If rented, attach a copy of the certificate of insurance from the rental company.)
12. Does applicant confirm neighboring properties are properly underpinned or stabilized prior to
excavating? ................................................................................................................................................
Yes No
13. Does applicant have snow/ice removal operations? ............................................................................. Yes No
If yes: Annual payroll from snow/ice removal: $
Any snow/ice removal operations on public streets or roads? ....................................................... Yes No
14. Any underground tanks, petroleum products, LPG, flammable liquids, ammunition or explo-
sives stored on premises? .......................................................................................................................
Yes No
If yes, type and quantity stored:
15. Does applicant do excavation for swimming pools? ............................................................................. Yes No
If yes, advise payroll: $ and receipts: $ .
16. Any equipment loaned, leased or rented to others without operator? ................................................ Yes No
If yes, describe type of equipment:
Annual rental (with operator) receipts: Annual rental (without operator) receipts:
17. Does applicant subcontract work? .......................................................................................................... Yes No
If yes, state type of work:
18. Are certificates of insurance obtained from subcontractors? ............................................................. Yes No
If yes, limits of liability required on certificates:
19. Any work involving underground storage tank installation or removal; tunneling; earthen dam
construction; river channeling or re-channeling; mining; work on landfills; public street or road
construction; or water main, sewer or pipeline construction? ............................................................
Yes No
If yes, describe:
20. Site preparation for residential? .............................................................................................................. Yes No
If yes:
Any single family home developments with more than twelve (12) home sites? ........................................ Yes No
Any condominiums or townhouses? ............................................................................................................ Yes No
21. 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:
22. Does applicant have other business ventures for which coverage is not requested? ...................... Yes No
If yes, explain and advise where insured:
GLS-APP-12s (10-13) Page 2 of 4
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.
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 civil penalty not to exceed five thousand dollars
and the stated value of the claim for each such violation.
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 to Oregon.)
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
addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the
applicant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any in-
surer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a
felony of the third degree.
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.
GLS-APP-12s (10-13) Page 3 of 4
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
under 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 civil penalty not to exceed five thousand dollars
and the stated value of the claim for each such violation.
APPLICANT’S NAME AND TITLE:
APPLICANT’S SIGNATURE: DATE:
(Must be signed by an active owner, partner or executive officer)
PRODUCER’S SIGNATURE: DATE:
GLS-APP-12s (10-13) Page 4 of 4
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EXCAVATORS AND GRADING OF LAND SUPPLEMENTAL APPLICATION (RT Specialty)

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Completed 13 December 2020

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