Fillable Form 12: CONTRACTORS APPLICATION VO A THROUGH MADE

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CONTRACTORS
APPLICATION
©
2014
WESTCAP
1
of
5
APP090814
AS
USED
IN
THIS
APPLICATION,
THE
“NAMED
INSURED”
IS
REFERRED
TO
AS
“APPLICANT”
OR
“YOU”.
AS
USED
IN
THIS
APPLICATION,
“
POLICY
YEAR
”
IS
THE
12
MONTH
PERIOD
FOR
WHICH
APPLICANT
SEEKS
TO
BE
COVERED
BY
THE
GENERAL
LIABILITY
INSURANCE
POLICY
WHICH
IS
THE
SUBJECT
OF
THIS
APPLICATION.
THE
“EXPIRING
POLICY
YEAR”
IS
THE
12
MONTH
PERIOD
PRIOR
TO
THE
DESIRED
POLICY
EFFECTIVE
DATE.
FOR
THE
PURPOSE
OF
DETERMINING
THE
PREMIUM
DUE
FOR
ANY
POLICY
ISSUED
PURSUANT
TO
THIS
APPLICATION,
“GROSS
RECEIPTS”
ARE
THE
NAMED
INSURED’S
TOTAL
RECEIPTS
DURING
THE
POLICY
PERIOD,
WITH
NO
DEDUCTION
FOR
THE
COST
OF
GOODS
OR
PROPERTY
SO
LD,
LABOR
COSTS,
INTEREST
EXPENSE,
DISCOUNTS
PAID,
DELIVERY
COSTS,
STATE
OR
FEDERAL
TAXES,
OR
ANY
OTH
ER
EXPENSES.
GROSS
RECEIPTS
WILL
BE
DEEMED
TO
INCLUDE
ANY
AND
ALL
PAYMENTS
MADE
THROUGH
A
VO
UCHER
SERVICE,
LENDER
OR
SIMILAR
ORGANIZATION
OR
SERVICE
WHICH
DISTRIBUTES
FUNDS
TO
SUBCONTRACTORS
,
INDEPENDENT
CONTRACTORS,
MATERIAL
SUPPLIERS,
EQUIPMENT
SUPPLIERS
OR
THE
LIKE
WITH
RESPECT
TO
ANY
PRO
JECT
FOR
WHICH
AN
INSURED
IS
SERVING
AS
A
GENERAL
CONTRACTOR
OR
REMODELING
CONTRACTOR,
OR
IN
A
SIMILAR
RO
LE.
1.
PRODUCER
NAME:
2.
PRODUCER
ADDRESS:
3.
PRODUCER
TELEPHONE:
5.
PRODUCER
FAX:
6.
PRODUCER
E
-
MAIL:
7.
APPLICANT
NAME
TO
BE
SHOWN
ON
POLICY
AS
NAMED
INSURED:
8.
SOLE
PROPRIETORSHIP
PARTNERSHIP
CORPORATION
JOINT
VENTURE
LLC
OTHER
9.
APPLICANT
’S
MAILING
ADDRESS:
10.
CITY:
11.
STATE:
12.
ZIP:
13.
APPLICANT
‘S
STREET
ADDRESS:
14.
CITY:
15.
STATE:
16.
ZIP:
17.
APPLICANT’S
OFFICE
PHONE
NUMBER:
18.
APPLICANT’S
CELL
PHONE
NUMBER:
19
.
APPLICANT’S
E
-
MAIL
ADDRESS:
20.
INSPECTION
CONTACT
NAME:
21.
CLAIMS
CONTACT
NAME:
22.
YEARS
APPLICANT
HAS
BEEN
IN
BUSINESS:
23.
NAMES
OF
PRIOR
OR
EXISTING
BUSINESSES
UNDER
COMMON
CONTROL
WITH
APPLICANT:
24.
TOTAL
YEARS
TRADE
EXPERIENCE
OF
APPLICANT
AND
PREDECESSORS:
25.
CONTRACTOR
LICENSE
NUMBER(S)
:
26.
LICENSED
STATE(S):
27.
TAX
ID
NUMBER:
28.
DESCRIPTION
OF
APPLICANT’S
CURRENT
AND
PROSPECTIVE
OPERATIONS
DURING
THE
POLICY
YEAR:
29.
DOES
APPLICANT
NOW
HAVE,
OR
WILL
APPLICANT
HAVE
DURING
THE
POLICY
YEAR,
ANY
OPERATIONS,
BUSINE
SS
ACTIVITIES
OR
SOURCES
OF
RE
VENUE
NOT
DESCRIBED
IN
ITEM
28
ABOV
E?
YES
NO
IF
YES,
DESCRIBE
THOSE
OPERATIONS:
30.
DOES
THE
APPLICANT
HAVE
SEPARATE
INSURANCE
FOR
THE
ACTIVITIES
DESCRIBED
IN
QUESTION
29
ABOVE?
YES
NO
IF
YES,
INSURANCE
COMPANY
NAME
AND
POLICY
#:
CONTRACTORS
APPLICATION
©
2014
WESTCAP
2
of
5
APP090814
31.
DOES
THE
APPLICANT
HAVE
ANY
OPERATIONS
DESCRIBED
IN
QUESTION
28
ABOVE
FOR
WHICH
IT
HAS
SEPA
RATE
INSURANCE
(INCLUDIN
G
WRAP-UP
COVERAGE)?
YES
NO
IF
YES,
PLEASE
PROVIDE
DETAILS
OF
COVERAGE:
POLICY
INFORMATION
:
32.
POLICY
EFFECTIVE
DATE:
33.
DEDUCTIBLE:
PER
CLAIM
PER
OCCURRENCE
34.
OCCURRENCE
LIMIT:
$
35.
GENERAL
AGGREGATE
LIMIT:
$
36.
PRODUCTS/COMPLETED
OPS.
AGG.
LIMIT:
$
37.
BLANKET
ADDITIONAL
INSURANCE
COVERAGE:
YES
NO
38.
BLANKET
WAIVER
OF
SUBROGATION:
YES
NO
39.
SUNSET
CLAUSE
LIMITATION:
YES
NO
40.
DAMAGE
TO
RENTED
PREMISES
LIMIT:
$50,000
$100,000
41.
LIST
SPECIFIC
ADDITIONAL
INSUREDS
IF
REQUIRED:
NAME
ADDRESS
42.
SPECIFIC
COVERAGE
REQUESTS:
43.
HAVE
YOU
PERFORMED
DURING
THE
THREE
(3)
YEAR
PERIOD
BEFORE
THE
POLICY
YEAR,
OR
WILL
YOU
PERFORM
DURING
THE
POLICY
YEAR,
ANY
OF
THE
FOL
LOWING
JOBS
OR
OPERATIONS?:
A.
AIRPORT
WORK
YES
NO
F.
DAMS,
LEVEES
OR
BRIDGES
YES
NO
K.
MOLD
REMEDIATION
YES
NO
P.
OIL
OR
GAS
WELL
DRILLING
YES
NO
B.
ASBESTOS
OR
LEAD
ABATEMENT
YES
NO
G.
EMPLOYEE
LEASING
YES
NO
L.
RAILROAD
S
YES
NO
Q.
EQUIPMENT
LEASING
YES
NO
C.
BLAST
ING
OPERATIONS
YES
NO
H.
WORK
OVER
3
STORIES
YES
NO
M.
SCAF
FOLD
ERECTION
YES
NO
R.
USE
OF
CRANES
OR
LIFTS
YES
NO
D.
CHEMICAL
SPRAYING
YES
NO
I.
FIRE
SPRINKLER
SYSTEMS
YES
NO
N.
EFIS
SYSTEMS
YES
NO
S.
EARTH
-
QUAKE
RETROFIT
YES
NO
E.
EXTERMINA
-
TION
OR
PEST
CONTROL
YES
NO
J.
TORCH
DOWN
OR
OPEN
FLAME
WORK
YES
NO
O.
CONSTRUC
-
TION
MANAGE-
MENT
FOR
A
FEE
YES
NO
T.
TRAFFIC
CONTROL
OR
TRAFFIC
SIGNALS
YES
NO
EXPLAIN
ALL
"YES"
RESPONSES:
DURING
THE
POLICY
YEAR
-
TYPE
OF
WORK
YOU
WILL
PERFORM:
44.
RESIDENTIAL
VS
COMMERCIAL
PROJECTS
=
100%
RESIDENTIAL
%
COMMERCIAL
%
45.
GEN.
CONTRACTOR
VS
SUBCONTRACTOR
=
100%
GENERAL
CONTRACTOR
%
SUBCONTRACTOR
%
46.
NEW
GROUND
UP
VS
REMODEL/REPAIR
=
100%
NEW
CONSTRUCTION
%
REMODELING
OR
REPAIR
%
HOW
MANY
BUILDINGS
WILL
YOU
WORK
ON
IN
THESE
CATEGORIES:
CUSTOM
HOMES
NOT
IN
TRACTS:
TRACT
HOMES
IN
2
TO
10
UNIT
TRACTS:
TRACT
HOMES
IN
11
TO
50
UNIT
TRACTS:
TRACT
HOMES
IN
TRACTS
OVER
50
UNITS:
48.
IN
THE
POLICY
YEAR,
HOW
MANY
BUILDINGS
WILL
YOU
WORK
ON
IN
THESE
CATEGORIES:
APARTMENTS:
CONDOMINIUMS:
TOWNHOUSES
OR
ROW
HOMES:
COMMERCIAL
BUILDINGS:
49.
DURING
THE
POLICY
YEAR,
WILL
YOU
PERFORM
ANY
WORK
FOR
CONDOMINIUM
/
TOWNHOUSE
DEVELOPERS
OR
HOMEOWNE
R
ASSOCIATIONS
(IN
THEIR
COMMON
AREAS
OR
OT
HERWISE)?
YES
NO
50.
DURING
THE
POLICY
YEAR,
WILL
YOU
DO
WORK
FOR
CONDOMINIUM
/
TOWNHOUSE
UNIT
OWNERS?
YES
NO
CONTRACTORS
APPLICATION
©
2014
WESTCAP
3
of
5
APP090814
51.
DO
YOU
HAVE
ANY
WORK
PLANNED
UNDER
OCIP
OR
“WRAP-UP”
PROJECTS
DURING
THE
POLICY
YEAR?
YES
NO
IF
YES,
WHAT
ARE
YOUR
EXPECTED
RECEIPTS
FROM
WORK
DONE
IN
“WRAP-UP”
PROJECTS?
FINANCIAL
INFORMATION
DOLLAR
($)
AMOUNTS:
PERIOD:
52.
YEAR
53.
GROSS
RECEIPTS
54.
SUBCONTRACTING
COSTS
55.
GROSS
PAYROLL
56.
#
OF
PROJECTS
WORKED
UPON
57.
#
OF
PROJECTS
COMPLETED
A.
UPCOMING
POLICY
YEAR
(ESTIMATED
$
AMOUNTS)
$
$
$
B.
EXPIRING
POLICY
YEAR:
$
$
$
C.
1
st
PRIOR
POLICY
YEAR:
$
$
$
D.
2
nd
PRIOR
POLICY
YEAR:
$
$
$
PRIOR
INSURANCE
COMPANY
INFORMATION:
PERIOD
58.
POLICY
PERIOD
59.
INSURANCE
COMPANY
60.
POLICY
NUMBER
61.
POLICY
PREMIUM
62.
POLICY
LIMITS
63.
POLICY
DED.
A.
EXPIRING
POLICY
YEAR
$
$
$
B.
1
ST
PRIOR
POLICY
YEAR
$
$
$
C.
2
ND
PRIOR
POLICY
YEAR
$
$
$
64.
HAS
APPLICANT
OR
ANY
OF
ITS
PREDECESSORS
OR
PRINCIPALS
EVER
BEEN
ADJUDGED
BANKRUPT
OR
INSOLVENT?
YES
NO
IF
YES,
PROVIDE
DETAILS:
65.
DOES
THE
APPLICANT
OR
ITS
PREDESSORS
HAVE
ANY
UNPAID
JUDGMENTS,
LIENS
OR
UNPAID
INSURANCE
PREMIUMS
OR
DEDUCTIBLE
S?
YES
NO
IF
YES,
PROVIDE
DETAILS:
66
.
STATES
IN
WHICH
THE
APPLICANT
HAS
PERFORMED
CONTRACTING
WORK
DURING
THE
THREE
YEARS
BEFORE
THE
POLICY
YEAR
OR
WILL
PERFORM
CONTRACTING
WORK
DURING
THE
POLICY
YEAR?
PLEASE
LIST
YOUR
THREE
LARGEST
JOBS
IN
THE
LAST
THREE
YEARS:
67.
PROJECT
NAME
&
TYPE
68.
DATE/YEAR
OF
WORK
69.
NATURE
OF
WORK
70.
GROSS
RECEIPTS
A
$
B
$
C
$
PLEASE
LIST
THE
TWO
LARGEST
PROJECTS
THAT
YOU
ARE
CURRENTLY
WORKING
ON
OR
WILL
COMMENCE
IN
THE
POLICY
YEAR:
71.
PROJECT
NAME
&
TYPE
72.
DATE/YEAR
OF
WORK
73.
NATURE
OF
WORK
74.
GROSS
RECEIPTS
A
$
B
$
75
.
WILL
YOU
USE
SUBCONTRACTORS
DURING
THE
POLICY
YEAR?
(IF
YES,
QUESTIONS
76,
77,
79
&
80
ARE
CONDITIONS
OF
ANY
POLICY
THE
COMPANY
MAY
ISSUE)
YES
NO
76.
DO
YOU
NOW,
AND
WILL
YOU
DURING
THE
POLICY
YEAR,
HAVE
A
WRITTEN
CONTRACT
WITH
EACH
OF
YOUR
SUBCONTRACTORS
WHICH
HOLDS
YOU
HARMLESS
RELATIVE
TO
WORK
PERFORMED
BY
THE
SUBCONTRACTOR?
YES
NO
77.
ARE
YOU
NOW
NAMED
AS
AN
ADDITIONAL
INSURED
ON
YOUR
SUBCONTRACTORS'
POLICIES,
AND
WILL
YOU
BE
NAMED
AS
AN
ADDITIONAL
INSURED
ON
SUCH
POLICIES
DURING
THE
POLICY
YEAR?
YES
NO
78.
DO
YOU
HOLD
OTHERS
HARMLESS
OR
ARE
YOU
REQUIRED
TO
PROVIDE
ADDITIONAL
INSURED
ENDORSEMENTS
FOR
OTHERS?
YES
NO
79
.
ARE
YOUR
SUBCONTRACTORS
REQUIRED
TO
PROVIDE
YOU
WITH
A
CERTIFICATE
OF
INSURANCE
BEFORE
COMMENCING
WORK,
DEMONSTRATING
THAT
THEY
HAVE
GENERAL
LIABILITY
INSURANCE
COV
ERAGE
FOR
THE
POLICY
YEAR?
YES
NO
CONTRACTORS
APPLICATION
©
2014
WESTCAP
4
of
5
APP090814
80
.
DO
YOU
REQUIRE
YOUR
SUBCONTRACTORS
TO
MAINTAIN
LIMITS
OF
LIABILITY
OF
AT
LEAST
$1,000,000
PER
OCCURRENCE?
YES
NO
81
.
DO
YOU
NOW,
OR
WILL
YOU
DURING
THE
POLICY
Y
EAR,
HAVE
ANIMALS
OF
ANY
TYPE
ON
YOUR
PREMISES
OR
AT
JOBSITES?
YES
NO
LOSS
AND
CLAIM
INFORMATION
(5
YEARS):
PERI
OD
82
.
YEAR
83
.
$
TOTAL
OF
LOSSES
84
.
#
OF
CLAIMS
85
.
LARGEST
LOSS
86
.
CAUSE
OF
LARGEST
LOSS
A.
EXPIRING
POLICY
YEAR
$
$
B.
1
ST
PRIOR
POLICY
YEAR
$
$
C.
2
ND
PRIOR
POLICY
YEAR
$
$
D.
3
RD
PRIOR
POLICY
YEAR
$
$
E.
4
TH
PRIOR
POLICY
YEAR
$
$
87.
ARE
YOU
AWARE
OF
ANY
FACTS,
CIRCUMSTANCES,
INCIDENTS,
SITUATIONS,
DAMAGES
OR
ACCIDENTS
THAT
MAY
GIVE
RISE
TO
A
CLAIM
OR
LAWSUIT
(WHET
HER
OR
NOT
SUCH
CLAIM
IS
VALID
OR
COVERED
BY
INSURANCE
)?
ANSWER
YES
OR
NO:
Yes
No
IF
YES
PLEASE
COMPLETE
QUESTIONS
88
THRU
91:
88
.
PROJECT
NAME
&
TYPE
89
.
DATE/YEAR
OF
WORK
90
.
NATURE
OF
YOUR
WORK
91
.
CLAIMED
DAMAGES
$
$
92
.
IN
THE
PAST
FIVE
YEARS,
HAS
ANY
LOCAL,
STATE
OR
FEDERAL
GOVERNMENT
AGENCY
OR
LICENSING
BOARD
INVESTIGATED
OR
CITED
APPLICANT
OR
ANY
PREDECESSOR
OR
PRINCIPAL
OF
APPLICANT
FOR
ACTUAL
OR
A
LLEGED
VIOLATION
OF
ANY
LAW
OR
REGULATION?
YES
NO
93
.
IN
THE
PAST
FIVE
YEARS,
HAS
APPLICANT
OR
ANY
PREDECESSOR
OR
PRINCIPAL
OF
APPLICANT
BEEN
THE
SUBJECT
OF
ANY
CLAIM,
OR
BEEN
NAMED
IN
LITIGATION
OR
ARBITRATION,
REGARDING
FAULTY
CONST
RUCTION?
YES
NO
94
.
IN
THE
PAST
FIVE
YEARS,
HAS
ANY
PERSON
OR
ENTITY
DEMANDED
THAT
APPLICANT,
OR
ANY
PREDECESSOR
OR
PRINCIPAL
OF
APPLICANT,
DEFEND
THEM,
OR
HOLD
THEM
HARMLESS,
IN
ANY
CLAIM
OR
LAWSUIT?
YES
NO
95
.
IN
THE
PAST
FIVE
YEARS,
HAS
ANY
LAWSUIT
BEEN
FILED
OR
CLAIM
BEEN
MADE
AGAINST
APPLICANT,
OR
ANY
PREDECESSOR,
PRINCIPAL
OR
AFFILIATE
OF
APPLICANT,
OR
ANY
PERSON
OR
ENTITY
ON
WHOSE
BEHALF
AP
PLICANT
HAS
ASSUMED
LIABILITY,
THAT
HAS
NOT
BEEN
DISCLOSED
ELSEWHERE
I
N
THIS
APPLICATION?
FOR
THE
PURPOSES
OF
QUESTIONS
92,
93
AND
94,
A
CLAIM
OR
LAWSUIT
INCLU
DES
A
RECEIPT
OF
A
DEMAND
FOR
MONEY,
SERVICES,
ARBITRATI
ON
OR
MEDIATION.
YES
NO
IF
APPLICANT
ANSWERED
QUESTIONS
92,
93,
94
OR
95
WITH
“YES”,
PLEASE
PROVIDE
THE
FOLLOWING
INFORMATION
FOR
EACH
CLAIM
AND
/OR
LAWSUIT:
96
.
PROJECT
NAME
97
.
PROJECT
TYPE
98
.
NATURE
OF
YOUR
WORK
99
.
CLAIMED
DAMAGES
$
$
$
IF THERE HAVE BEEN NO LOSSES, CLAIMS OR SUITS IN THE LAST 5 YEARS,
PLEASE CHECK HERE
CONTRACTORS
APPLICATION
©
2014
WESTCAP
5
of
5
A
PP090814
ATTENTION:
1
. THE
APPLICANT
WARRANTS
THAT
THE
ABOVE
STATEME
NTS
AND
PARTICULARS,
TOGETHER
WITH
ANY
ATTACHED
OR
APPENDED
DOCUMENTS
OR
MATERIALS
(“THIS
A
PPLICATION”),
ARE
TRUE
AND
COMPLETE
AND
DO
NOT
MISREPRESENT,
MISSTATE
OR
OMIT
ANY
MATERIAL
FACT
S.
2. THE
A
PPLICANT
UNDERSTANDS
THAT
THE
COMPANY
RE
LIED
UPON
THE
INFORMATION
CONTAINED
WITHIN
THIS
APPLICATION
TO
DETERMINE
ACCEPTABILITY,
RA
TES
AND
COVERAGE.
3. THE
A
PPLICANT
UNDERSTANDS
THAT
ANY
MISREPRE
SENTATION
OR
OMISSION
SHALL
CONSTITUTE
GROUNDS
FOR
RECISSION
OF
COVERAGE
AND
DENIAL
OF
CLAIMS.
4
. THE
A
PPLICANT
UNDERSTANDS
THE
COMPANY
IS
NOT
OB
LIGATED
NOR
UNDER
ANY
DUTY
TO
ISSUE
A
POLICY
OF
INSURANCE
BASED
UPON
THIS
APPLICATION.
TH
E
APPLICANT
FURTHER
UNDERSTANDS
THAT,
IF
A
POLICY
IS
ISSUED,
THIS
APPLICATION
WILL
BE
INCORPO
RATED
INTO
AND
FORM
A
PART
OF
SUCH
POLICY.
5. IF
T
HE
APPLICANT
BECOMES
AWARE
THAT
ANY
RESPONS
E
ON
THIS
APPLICATION
BECOMES
INACCURATE
AS
A
RESULT
OF
INFORMATION
OR
CHANGE
OF
CIRCUM
STANCES
BEFORE
A
POLICY
IS
ISSUED,
THE
APPLICANT
MUST
INFORM
THE
COMPANY
OF
SUCH
CHANGE,
IN
WRITI
NG,
AND
ANY
POLICY
ISSUED
BEFORE
SUCH
NOTIFICATION
IS
SUBJECT
TO
IMMEDIATE
CANCELLATION.
6
. THE
A
PPLICANT
AUTHORIZES
THE
COMPANY
TO
MAKE
AN
Y
INVESTIGATION
AND
INQUIRY
IN
CONNECTION
WITH
THE
QUESTIONNAIRE
AS
IT
MAY
DEEM
NECESSARY.
THE
U
NDERSI
GNED,
BEING
AUTHORIZED
BY
AN
D
ACTING
ON
BEHALF
OF
THE
PROSPECTIVE
INSUREDS,
REPRESENTS
THAT
THE
ANSWERS
GIVEN
ARE
TRUE.
FA
ILURE
TO
PROVIDE
TRUTHFUL
ANSWERS
AND
ALL
MATERIAL
INFORMATION
CAN
RESULT
IN
THE
COMP
ANY
ELECTING
TO
CANCEL,
REFORM
AND/OR
RESCIND
THE
POLICY.
WASHINGTON
R
ESIDENTS:
NO
ORAL
OR
WRITTEN
MIS
REPRESENTATION
OR
FALSE
WARRANTY
MADE
IN
THE
NEGOTIATION
OF
AN
INSURANCE
CONTRACT
BY
THE
INSU
RED
OR
ON
THE
INSURED’S
BEHALF
SHALL
BE
DEEMED
MATERIAL
OR
DEFEAT
OR
AVOID
THE
CONTRACT
OR
PRE
VENT
IT
ATTACHING
UNLESS
THE
MISREPRESENTATION
OR
FALSE
WARRANTY
IS
MADE
WITH
INTENT
TO
DECEIVE.
THE
T
E
RMS,
CONDITIONS
AND
EXCLUSIONS
CON
TAINED
IN
ANY
POLICY
ISSUED
PURSUANT
TO
THIS
APPLICATION
WILL
VARY
SIGNIFICANTLY
FROM
THOSE
CONT
AINED
IN
MANY
OTHER
LIABILITY
INSURANCE
POLICIES.
THE
COMPANY’S
POLICY
FORM
PROVIDES
COVERAGE
TH
AT
MAY
BE
MORE
LIMITED
THAN
THAT
PROVIDED
UNDER
THE
“ISO”
INSURANCE
POLICY
OR
THE
POLICIES
ISSUED
BY
OT
HER
COMPANIES.
YOU
SHOULD
CAREFULLY
REVIEW
THE
ENTIRE
POLICY
WITH
YOUR
AGENT
OR
OTHER
INSURANC
E
PROFESSIONAL
TO
MAKE
SURE
THAT
YOU
UNDERSTAND
THE
COVERAGE
THAT
IT
PROVIDES,
AND
YOUR
RIGHTS
A
ND
OBLIGATIONS
UNDER
THE
POLICY.
(“APPLICANT”,
“
YOU”,
“YOUR”
AND
SIMILAR
WORDS
RE
FER
TO
THE
PROSPECTIVE
INSURED)
Signature
of
Applicant:
Date:
Title
(Officer,
Member,
or
Owner)
A
NY
PERSON
WHO,
WITH
INTENT
TO
DEFRAUD
OR
KNOW
ING
THAT
HE
IS
FACILITATING
A
FRAUD
AGAINST
AN
INSURER,
SUBMITS
AN
APPLICATION
OR
FILES
A
CL
AIM
CONTAINING
A
FALSE
OR
DECEPTIVE
STATEMENT
IS
GUILTY
OF
INSURANCE
FRAUD.
W
ASHINGTON
RESIDENTS:
IT
IS
A
CRIME
TO
KNOWING
LY
PROVIDE
FALSE,
INCOMPLETE,
OR
MISLEADING
INFORMATION
TO
AN
INSURANCE
COMPANY
FOR
THE
PURP
OSE
OF
DEFRAUDING
THE
COMPANY.
PENALTIES
INCLUDE
IMPRISONMENT,
FINES,
AND
DENIA
L
OF
INSURANCE
BENEFITS.
EMAIL
, FAX OR MAIL
APPLICATION
TO
WESTCAP
INSURANCE
SERVICES,
LLC
.
2029 VILLAGE LANE
,
SUITE
200,
SOLVANG,
CA
93463
PHONE
(805)
688-4995
FAX
(805)
688-2668
application@treancorp.com
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Form 12: CONTRACTORS APPLICATION VO A THROUGH MADE

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Completed 30 November 2021

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