Fillable Fire Sprinkler Contractor General Liability Application (RT Specialty)

Fill Online, Printable, Fillable, Blank Fire Sprinkler Contractor General Liability Application (RT Specialty) Form

Use Fill to complete blank online RT SPECIALTY pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Fire Sprinkler Contractor General Liability Application (RT Specialty)

On average this form takes 94 minutes to complete

The Fire Sprinkler Contractor General Liability Application (RT Specialty) form is 6 pages long and contains:

  • 2 signatures
  • 18 check-boxes
  • 359 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your RT Specialty forms online.

BROWSE RT SPECIALTY FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
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
Fire Sprinkler Contractor General Liability Application
Applicant’s Name Agency Name
Mailing Address Agent
Address
Location
E-mail
Web site Address Phone
PROPOSED EFFECTIVE DATE: From To 12:01 A.M., Standard Time at the address of the Applicant
Applicant is: Individual Corporation Partnership Joint Venture
Limited Liability Company Other (Specify):
ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE NOT APPLICABLE
LIMITS OF LIABILITY REQUESTED PREMIUMS
General Aggregate $
Premises/Operations
Products & Completed Operations Aggregate $
$
Personal & Advertising Injury $
Products/Completed Operations
Each Occurrence $
$
Fire Damage (any one fire) $
Other
Medical Expense (any one person) $
$
Other Coverages, Restrictions, and/or Endorsements Total
Deductible $
$
1. Contact person: Title:
Contact person is: Owner General Manager Other:
Daytime phone number: Nighttime phone number:
Fax number: E-mail address:
2. How long have you been in business? yrs. Total number of employees:
3. Are you licensed? ...................................................................................................................................... Yes No
If no, explain:
GLS-APP-77s (9-08) Page 1 of 6
Submit Here
Number of employees with NICET Certification: Level I Level II
Level III Level IV
4. Estimated annual
a. Payroll $ b. Sales $
5. Your Operations (show sales and payroll for each) Payroll Sales
a. Retrofit (vacant) $
$
b. Retrofit (occupied) $
$
c. Design $
$
d. Service / Repair $
$
e. Inspection $
$
f. New Installation $
$
g. Other—Describe: $
$
h. Does applicant have other business ventures for which coverage is not requested? ...................... Yes No
If yes, explain and advise where insured:
6.
Aircraft Hangers
% Government Buildings
% Offshore Exposure
%
Apartments
% Hospitals
% Rack Storage
%
Casinos
% Hotels
% Refineries
%
Chemical, Fertilizer or
Petrochemical
% Manufacturing % Schools %
Churches
% Mercantile
% Single Family
%
Condos/Townhouses
% Nuclear Power Plants
% Theaters > 100 Seating
%
Detention/Correctional
Facilities
% Nursing Homes % Warehouses %
Special Hazards:
% Describe:
%
7. Do you install extinguishing systems in vehicles, mobile equipment, watercraft, or aircraft? ........ Yes No
If yes, explain:
8. Types of Sprinkler Systems
Installation/Repair/Service Inspection Type Designed by You
Deluge
% Deluge
%
Dry Pipe
% Dry Pipe
%
Hydraulically Calculated
% Hydraulically Calculated
%
Preaction
% Preaction
%
Wet Pipe
% Wet Pipe
%
Special Hazards: Special Hazards:
Carbon Dioxide
%
Carbon Dioxide
%
Dry Chemicals
% Dry Chemicals
%
Foam
% Foam
%
GLS-APP-77s (9-08) Page 2 of 6
9. Do you do any manufacturing or sell anything under your own label? .............................................. Yes No
If yes, explain:
10. Do you sell any items other than items which are installed by you? .................................................. Yes No
If yes, provide listing of products sold:
Sales amount for these products?
11. Do you do design work for others? ......................................................................................................... Yes No
If yes, percent of operation: .......................................................................................................................... %
How do you handle requirements for PE stamp/seal?
12. Are design plans approved by:
Architects? ................................................................................................................................................... Yes No
Municipal Authorities?.................................................................................................................................. Yes No
13. List your employees who design or modify plans and their experience.
Name of Employee NICET Level
Years Of
Design
Experience
14. Do you design systems without performing installation? .................................................................... Yes No
If yes, percent of operation: .......................................................................................................................... %
15. How often do you inspect and service customers’ fire sprinkler equipment?
16. Are detailed records kept on all jobs? .................................................................................................... Yes No
If yes, for how long:
17. Have you ever installed any sprinkler heads that were subject to recalls? ........................................ Yes No
If yes, name the brand:
If yes, have the sprinkler heads been replaced? ......................................................................................... Yes No
If no, explain:
18. Describe the procedure used for turning the fire sprinkler system over to the building owners:
19. Describe the procedure used to document the distribution of NFPA 25 requirements to the building owners:
20. Have you ever been involved or plan to be involved during the next twelve (12) months with a
“wrap-up or OCIP”?...................................................................................................................................
Yes No
GLS-APP-77s (9-08) Page 3 of 6
If yes, please provide the following information:
Project Name Date Project Description Location Revenues
21. List all major projects completed within the last three years, including work in progress and planned projects.
(List project name, date, project description, location, and revenues.)
Project Name Date Project Description Location Revenues
22. Do you have an ongoing in-house training program for sprinkler fitters? ......................................... Yes No
If yes, describe:
23. Do you and your employees participate in the following professional organizations:
AFSA NICET NFPA NFSA SFPE Other:
24. Do you have Workers’ Compensation coverage in force? ................................................................... Yes No
25. Do you lease employees? ......................................................................................................................... Yes No
26. Do you subcontract work to others? ....................................................................................................... Yes No
If yes, indicate type of work and cost:
Are certificates of insurance obtained from all subcontractors? .................................................................. Yes No
What limits of liability do you require from all subcontractors?
27. What percentage of your work is with repeat customers? .................................................................... %
28. List the states you have worked in during the last five years:
29. Please attach:
(A) Any descriptive or advertising literature;
(B) Copy of usual performance contract with client;
(C) Any hold harmless agreements executed in favor of client.
30. Do you limit your liability to a stated dollar amount (liquidated damages) on your contract with
your clients? ..............................................................................................................................................
Yes No
If yes, what is the maximum limit allowed?
What percentage of your contracts waives the liquidated damages clause?............................................... %
31. During the past three years, has any company ever canceled, declined or refused to issue
similar insurance to you (Not applicable in Missouri)? .............................................................................
Yes No
If yes, explain:
GLS-APP-77s (9-08) Page 4 of 6
32. Have you ever been named in claims or litigation regarding faulty or defective construction or
workmanship? ...........................................................................................................................................
Yes No
If yes, provide details and include how the issue was corrected or resolved:
Previous Insurer and 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 or attach currently valued loss runs.
YEAR COMPANY
POLICY
NUMBER PREMIUM
LOSSES
PAID
LOSSES
RESERVED DESCRIPTION
SCHEDULE OF HAZARDS
Loc.
No.
Classification
Class.
Code
Premium Bases:
(s) Gross Sales
(p) Payroll (a) Area
(c) Total Cost (t) Other
Terr.
Rate Premium
Prem./
Ops.
Products
Prem./
Ops.
Products
PROVIDE DETAILS OF ALL LOSSES IN EXCESS OF TEN THOUSAND DOLLARS ($10,000).
DO YOU HAVE THE FOLLOWING (IF YES, ATTACH COPY)?
Copy of usual performance contract with client? ............................................................................................... Yes No
Descriptive advertising literature? ...................................................................................................................... Yes No
Hold harmless agreements executed in favor of client? .................................................................................... Yes No
Installation warranty? ......................................................................................................................................... Yes No
Written safety program? ..................................................................................................................................... Yes No
This application does not bind the applicant nor the Company to complete the insurance, but it is agreed that the
information contained herein shall be the basis of the contract should a policy be issued.
GLS-APP-77s (9-08) Page 5 of 6
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.
FRAUD WARNING NOTICE TO FLORIDA APPLICANTS:
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 the third degree.
FRAUD WARNING 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.
FRAUD WARNING 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.
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 an 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-77s (9-08) Page 6 of 6
click to sign
signature
click to edit
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Fire Sprinkler Contractor General Liability Application (RT Specialty)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 13 December 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document