Fillable FORECLOSURE/EVICTION CLEANUP SUPPLEMENTAL APPLICATION (RT Specialty)

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FORECLOSURE/EVICTION CLEANUP 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
FORECLOSURE/EVICTION CLEANUP SUPPLEMENTAL APPLICATION
(Complete in addition to ACORD General Liability Application)
Name of Applicant:
Web site Address:
State/Area of Operations:
ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE”
1. Provide details of all operations:
2. Applicant’s Operations:
Number of Owner/Partners: Payroll: No. of Trade Employees:
Operation is (% of each):
Residential % Commercial % Industrial %
Other: Describe %
3. Applicant provides services to (% of each):
Banks or other Financial Institutions % Realty Company or Broker % General Contractor %
Current Owner of property % New Owner of property %
Other: Describe %
4. Receipts/Sales:
Current Year: Previous Year: Two Years Ago:
Average Number of Jobs per month: Average Receipts per Job:
Does applicant retain any items of value for resale? ................................................................................... Yes No
If yes, annual receipts from sale of these items:
5. Subcontracted Work Cost:
Uninsured Subcontractors cost $
Insured Subcontractors cost $
Subcontracted work costs as percentage of total annual receipts: ................................................................. %
6. Describe equipment used in operations:
GLS-APP-79s (9-11) Page 1 of 4
Submit Here
7. List three current projects: (If less than three, include most recent completed projects)
Customer Name and Project Description Receipts Duration of Project
a.
b.
c.
8. List largest jobs in the last three years:
Customer Name and Project Description Receipts Duration of Project
a.
b.
c.
9. Has applicant ever acted in the capacity of a General Contractor? ..................................................... Yes No
If yes, provide details:
10. Has applicant ever acted in the capacity of a Construction/Project Manager or Construction
Consultant? ................................................................................................................................................
Yes No
If yes, provide details:
11. Any operations as a Property Inspector? ............................................................................................... Yes No
12. Indicate percentage of total operations performed by applicant or subcontractors for the following (Percent-
ages should total 100%):
Asbestos removal
% Landscaping
%
Carpentry—interior
% Landscape maintenance
%
Debris/Junk/Trash removal
% Masonry
%
Demolition interior—non-structural
% Meth lab cleanup
%
Demolition exterior or interior structural
% Mold or spore treatment or remediation
%
Door or window installation
% New construction site cleanup/make ready
%
Drywall
% New residential home construction
%
Electrical
% Painting—interior
%
Eviction processes or procedures
% Painting—exterior
%
Excavating or grading of land
% Plastering or stucco
%
Fence erection or repair
% Plumbing
%
Fire and water restoration
% Roofing
%
Fire suppression systems
% Room additions
%
Flooring—installation or refinishing
% Snow/Ice removal
%
Hazardous waste removal
% Tile, stone, marble, or terrazzo work
%
Heating/Air conditioning
% Tree trimming
%
Install new cabinets or countertops
% Waterproofing
%
Janitorial—general cleaning
% Window cleaning
%
Other: (describe)
%
Other: (describe)
%
13. Does applicant use a written contract with customers? ....................................................................... Yes No
If no, explain when not required:
14. Does applicant have Workers’ Compensation coverage in force? ...................................................... Yes No
GLS-APP-79s (9-11) Page 2 of 4
15. Subcontracted Work:
a. List the subcontracted trades used and the percentage of total operations:
Carpentry % / % / % / %
Plumbing % / % / % / %
Electrical % / % / % / %
Heating/Air % / % / % / %
b. Does applicant use a written contract with subcontractors? ................................................................. Yes No
If no, explain when not required:
If yes, do contracts include a hold harmless agreement in favor of the applicant? .............................. Yes No
c. Does applicant obtain certificates of insurance from all subcontractors? ............................................. Yes No
If yes, minimum limits required:
d. Is applicant added as an additional insured on the subcontractors’ liability policies? .......................... Yes No
16. Has applicant been involved in any claims involving construction defects? ..................................... Yes No
If yes, explain:
17. Have all tenants or occupants been evicted prior to applicant’s work activities? ............................. Yes No
If no, describe procedure/process followed prior to beginning work:
18. Does applicant own or have title to any locations undergoing cleanup/renovation? ........................ Yes No
19. Does applicant have other business ventures for which coverage is not requested? ...................... Yes No
If yes, explain and advise where insured:
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 to Nebraska, Oregon or Vermont).
NOTICE TO COLORADO APPLICANTS: 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 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.
GLS-APP-79s (9-11) Page 3 of 4
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 and willfully presents a false or fraudulent claim for
payment of a loss or benefit or who knowingly and 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 knowingly and with intent to defraud any insurance company 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.
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 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 include imprisonment, fines, and denial of insurance benefits.
FRAUD WARNING APPLICABLE IN THE STATE OF 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 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 NAME AND TITLE:
APPLICANT’S SIGNATURE: ___________________________________________________ DATE:
(Must be signed by active owner, partner or executive officer.)
PRODUCER’S SIGNATURE: _______________________________________________________________ DATE:
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.
GLS-APP-79s (9-11) Page 4 of 4
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FORECLOSUREEVICTION CLEANUP SUPPLEMENTAL APPLICATION (RT Specialty)

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Completed 13 December 2020

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