Fillable Fire Suppression & Extinguisher Installation, Service or Repair (All Risks, Ltd)

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Fire Suppression & Extinguisher Installation, Service or Repair (All Risks, Ltd)

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National Specialty Programs
Toll-Free: 800-366-5810 • Fax: 410-828-8179
Contact us: programs@ryansg.com
Fire Suppression & Extinguisher Installation, Service or Repair Application
General Information
1. Name: _____________________________________________________________________________________________
2. Physical Address: _____________________________________________________________________________________
Street City/County/State/Zip
3. Mailing Address: ______________________________________________________________________________________
Street City/County/State/Zip
4. Insured Email Address: _________________________________________________________________________________
5. Inspection Contact: ___________________________________ Phone: _____________________________
Audit Contact: ___________________________________ Phone: _____________________________
Claims Contact: ___________________________________ Phone: _____________________________
6. Phone Number: _____________________________ Fax: _______________________________
7. Website: _______________________________________________________ FEIN: ______________________________
8. Date Established: _____________________ License No. _______________________
Sole Proprietor Partnership Corporation Other: __________________________
9. Policy proposed effective date: _______________________ to __________________________
10. Current coverage expires/expired on: __________________________
11. Deductible: $1,000 $2,500 $5,000 Other: ___________________
12. Operations
Field Payroll
Sales
Automatic sprinkler installation, service, and/or repair
$
$
Chemical/Ansul Systems
$
$
Fire extinguisher servicing, refilling and/or testing
$
$
Grease cleaning
$
$
Alarm installation*
$
$
Alarm monitoring*
$
$
Design
$
$
Clerical
$
$
Other: _________________________
$
$
Retail sales of equipment (please describe): __________________________
$
$
*Please complete the first two pages of the Alarm Supplemental Application found on our website.
13. Does the applicant use any subcontractors? Yes No
If yes, please indicate annual cost? $ ___________________
a. What kind of work is subcontracted: _______________________________________________________
_____________________________________________________________________________________
b. Does the applicant obtain Certificates of Insurance? Yes No
c. Is the applicant added as an additional insured by their subcontractors? Yes No
d. Does the applicant verify all subcontractors carry equal or greater limits of insurance
and verify they are provided hold harmless status? Yes No
Fire Suppression Application 010721 Page 1 of 5
RSGprograms.com
14. Indicate percentage of:
Operations
Client Base
New Installations
%
Commercial
%
Retrofit/Renovations:
Institutional
%
Occupied
%
Industrial
%
Unoccupied
%
Apartments
%
Vacant
%
Single Family
%
Design
%
Condos
%
Service/Repair
%
Tract Housing
%
Inspection/Testing
%
Custom Homes
%
Total
100%
Hospitals
%
Penal Institutions
%
Theaters >100 seating
%
Restaurants
%
Total
100%
15. Does the applicant install, service and/or repair fire suppression systems aboard aircrafts, automobiles,
mobile equipment, boats or yachts? Yes No
If yes, please describe: _________________________________________________________________________
____________________________________________________________________________________________
16. Does the applicant fill any type of oxygen tanks? Yes No
17. Does the applicant design sprinkler systems or extinguisher systems? Yes No
a. If yes, what qualifications do the designers have: NICET III PE (Professional Engineer)
Other (please describe): ____________________
b. Does the applicant provide design work for others? Yes No
18.
Does the applicant do any retrofit and/or tenant improvement work on residential properties?
Yes No
If yes, what percentage? _____________ %
19. How does the applicant protect their workers from exposure to asbestos? _______________________________________
____________________________________________________________________________________________________
20. Do the job proposals include an asbestos clause allowing for the removal of asbestos prior to
work completion? Yes No
21. Does the applicant use PVC or CPVC piping? Yes No
a. If yes, what percentage of their installations are PVC or CPVC? _________ %
b. Does the insured strictly adhere to the manufacturer’s cure times? Yes No
c. Is pressure testing completed according to the manufacturer’s specifications? Yes No
d. Are all installers properly certified by the applicable manufacturers? Yes No
e. Are training or certifications renewed every 2 years? Yes No
f. Is CPVC/PVC piping used in wet sprinkler systems only? Yes No
g. Does the insured use CPVC piping and fittings that are in their original packaging? Yes No
h. Where is the CPVC/PVC piping stored? _____________________________________________________
22. Does the applicant manufacture any fire protection equipment? Yes No
23. Does the applicant sell any type of protective clothing or life support equipment? Yes No
If yes, please describe: __________________________________________________________________________
24. Does the applicant do any trenching work? Yes No
25. Describe applicant’s training program for technicians and/or service personnel: ___________________________________
____________________________________________________________________________________________________
26. Describe screening procedures for prospective employees: ____________________________________________________
____________________________________________________________________________________________________
27. Is the applicant a member of any professional associations? Yes No
If yes, please describe: __________________________________________________________________________
Fire Suppression Application 010721 Page 2 of 5
RSGprograms.com
28. Does the applicant perform any work within the 5 Boroughs of New York? Yes No
If yes, what percentage: _________ %
QUALITY & SAFETY CONTROLS
1. Are shop drawings for sprinkler system installations prepared by the applicant? Yes No
If yes, describe how such drawings are checked for compliance with the specifications of
the system: __________________________________________________________________________________
____________________________________________________________________________________________
2. Is there a procedure when a system impairment is found or created? Yes No
If yes, please explain: __________________________________________________________________________
3. How does the field supervisor assure quality (i.e. checklists, daily visits etc.)? _____________________________________
____________________________________________________________________________________________________
4. Are records maintained on all service, repair, and/or testing performed? Yes No
a. If yes, are inspections and test certificates documented in the permanent job file?
b. How long are records retained? __________________________________________________________________
5. Who at the applicant’s firm verifies at job completion that all work complies with NFPA standards? ___________________
____________________________________________________________________________________________________
6. What specific warranties do you give on an outright sale? _____________________________________________________
____________________________________________________________________________________________________
7. Total Number of Employees:
Full-Time
Part-Time
Employees (other)
Field Employees
Total
Additional Coverages (Check all that apply):
Additional Insureds: Individual Blanket
Waiver of Subrogation: Individual Blanket
Primary Wording: Individual Blanket
Per Project Aggregate Employee Benefits Liability Stop Gap Hired/Non-Owned Auto
CURRENT GENERA
L LIABILITY INFORMATION
1. Please provide name of carriers, premiums paid, limits, sales, deductibles, and loss runs for the past 5 years.
YR: _______
YR: _______
YR: _______
YR: _______
YR: _______
Carrier
Premium
Payroll
Deductible
Losses
2. Has any company canceled or declined to renew in the past 5 years? Yes No
If yes, please explain: __________________________________________________________________________
____________________________________________________________________________________________
3. Has the applicant ever had a lapse in coverage? Yes No
If yes, please explain: __________________________________________________________________________
____________________________________________________________________________________________
Fire Suppression Application 010721 Page 3 of 5
RSGprograms.com
Yes No
CLAIM INFORMATION
1. Make sure to attach 5 years of currently valued loss runs. (Valued no more than 3 months from date of application.)
2. Does Applicant require staff to report all unusual incidents and are all incident reports reviewed
by management? Yes No
3. Does Applicant have any knowledge concerning any incidents that have occurred prior to the date of
this application that may give rise to a future claim? Yes No
NOTICE TO APPLICANTS: THIS APPLICATION MUST BE COMPLETED IN FULL AS THE QUOTE WILL BE BASED SOLELY ON THE
INFORMATION PROVIDED, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER
PERSON, FILES AN APPLICATION FOR INSURANCE CONTAINING FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF
MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A
CRIME BY SIGNING THIS APPLICATION, THE SIGNOR WARRANTS THAT TO THEIR BEST KNOWLEDGE ALL INFORMATION GIVEN IS
TRUE AND ACCURATE.
___________________________________ ___________________________________ ___________________
Name (type or print) Signature Date
NOTICE TO PRODUCERS: THE PRODUCER HEREBY WARRANTS THAT THE INFORMATION CONTAINED IN THIS APPLICATION IS TRUE
AND CORRECT TO THE BEST OF THEIR KNOWLEDGE.
_______________________________ _______________________________ ___________________ ___________________
Name (type or print) Signature Date License Number
Please comple
te below if requesting Auto, Umbrella, or Workers’ Compensation coverage.
a. Are applicants’ MVRs reviewed upon hire and annually thereafter? Yes No
b. Are standards for acceptable drivers in place? Yes No
c. Is an action plan in place if acceptability standards are not met? Yes No
d. Are all drivers between 21 and 70 years old? Yes No
e. If over 70, are medical certificates stating that, he/she has no medical issues that would
preclude him/her from driving, available? Yes No
f. Does the insured have an acceptable Fleet Safety Program in place? Yes No
g. Is a Vehicle Maintenance Program in place? Yes No
h. Is personal usage of vehicles allowed? Yes No
i. Does the insured have a written personal use policy in place? Yes No
j. Is the original cost new of all vehicles less than $75,000? Yes No
If you answered “No” to any of the above, please explain: ____________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Fire Suppression Application 010721 Page 4 of 5
R
SGprograms.com
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UMBRELLA QUESTIONNAIRE
Please complete only if requesting umbrella coverage.
**ACORD Application & 5 Years of Auto Loss Runs required for Umbrella coverage.
1. With the exception of lienholders, are any vehicles not solely owned by and registered to the applicant? Yes No
2. Do over 50% of the employees use their autos in the business? Yes No
3. Are any vehicles leased to others? Yes No
4. Are any vehicles customized, altered or have special equipment? Yes No
5. Do operations involve transporting hazardous material? Yes No
6. Are any vehicles used by family members or non-employees? Yes No
7. Does the applicant have a specific driver recruiting method? Yes No
If you answered “Yes” to any of the above questions, please explain: ___________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
WORKERS’ COMPENSATION
Information Required with Submission (Please attach):
• ACORD Workers’ Compensation Application
• 5 Years Currently Valued Loss Run Statements
• Experience Modification Worksheet
• Risk Identification Number for the NCCI or Appropriate State Rating Bureau or State Fund
1. Is the current coverage now in Assigned Risk, State Fund or Voluntary Market? Yes No
2. Has any insurance carrier canceled or refused to renew within the past 3 years? Yes No
If yes, please explain: _________________________________________________________________________
___________________________________________________________________________________________
3. Employee Benefits Program: Group Medical 401k Other: ________________________________
4. Do you have a transitional duty (light duty) program? Yes No
If yes, please describe: __________________________________________________________________________
_____________________________________________________________________________________________
5. Who is responsible for safety? __________________________________________________________________________
6. Do you have a formal safety committee? Yes No
If yes, how frequently does it meet and who attends? _________________________________________________
_____________________________________________________________________________________________
WC WAIVER OF SUBROGATION
Blanket Individual
Please provide the names, addresses & class codes/payroll of all contracts
requiring an individual waiver of subrogation.
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Fire Suppression Application 010721 Page 5 of 5
RSGprograms.com
RSG National Specialty Programs is a unit of the RSG Underwriting Managers division of RSG Specialty, LLC, a Delaware limited liability company based in Illinois. RSG Specialty, LLC, is a
subsidiary of Ryan Specialty Group, LLC (RSG). RSG National Specialty Programs works directly with brokers, agents and insurance carriers, and as such does not solicit insurance from the
public. Some products may only be available in certain states, and some products may only be available from surplus lines insurers. In California: RSG Specialty Insurance Services, LLC
(License # 0G97516). ©2021 Ryan Specialty Group, LLC
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Completed 20 January 2021

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