Fillable General Contractors/Developers General Liability Application (RT Specialty)

Fill Online, Printable, Fillable, Blank General Contractors/Developers 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.

General Contractors/Developers General Liability Application (RT Specialty)

On average this form takes 145 minutes to complete

The General Contractors/Developers General Liability Application (RT Specialty) form is 16 pages long and contains:

  • 3 signatures
  • 28 check-boxes
  • 555 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
General Contractors/Developers General Liability Application
Applicant’s Name:
Mailing Address:
Location Address:
Agency Name:
Agent:
Address:
E-mail:
Phone No.:
PROPOSED EFFECTIVE DATE: From To 12:01 A.M., Standard Time at the address of the Applicant
ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE” (N/A)
Applicant is: Individual Corporation Partnership Joint Venture
Limited Liability Company Other (Specify)
Website Address:
E-mail Address: Phone Number:
Audit Contact Name:
E-mail Address: Phone Number:
Limits Of Liability and Deductible Requested:
General Aggregate (other than Products/Completed Operations)
$
Products & Completed Operations Aggregate $
Personal & Advertising Injury (any one person or organization) $
Each Occurrence $
Damage To Premises Rented To You (any one premise) $
Medical Expense (any one person) $
Other Coverages, Restrictions and/or Endorsements:
$
Deductible $
GLS-APP-8s (10-13) Page 1 of 10
Submit Here
1. Indicate percentage of work applicant performs in each of the following:
General Contractor ....................................... % Subcontractor ............................................. %
Developer ..................................................... % Construction/Project Manager/Consultant %
Owner/Builder ............................................... %
2. States/areas of operations:
Radius of operations from main location: miles.
3. Describe all operations in detail:
4. Any change in the named insured in the last year? .............................................................................. Yes No
If yes, advise all prior names:
5. Any change in operations in the last year? ............................................................................................ Yes No
If yes, advise:
6. Length of time in business: years. Years of experience:
Is applicant licensed? .................................................................................................................................. Yes No
If yes, type of license and number: Year license issued:
Length of time in business operating under the name shown above: years or new venture.
Has applicant operated or been licensed under any other name(s) during the past ten (10) years? .. Yes No
If yes, provide prior name and describe type of operations:
Prior Name
Operations Description
7. Total number of employees?
8. Indicate percent (%) of operations involving:
a. New construction % Remodeling ................. % Demolition ..................... %
Repair ................... % Other (explain below) % (Must total 100%)
Explain other:
b. Commercial new construction ................. % Commercial remodeling ................................ %
Industrial .................................................. % Institutional .................................................... %
Residential new construction .................. % Residential remodeling ................................. %
Apartments .............................................. % Commercial Condominiums .......................... %
Prefab/Modular/Kit home construction .... % Prefab/Modular/Kit home mfg ....................... %
(Must total 100%)
c. Residential new construction:
(1) Condos/Townhouses (including conversions) ................................................................................ %
(2) Single family or residential dwellings .............................................................................................. %
Average cost of new homes built:................................................................................................ $
GLS-APP-8s (10-13) Page 2 of 10
d. Residential remodeling:
(1) Interior work only ............................................................................................................................ %
(2) Ground-up construction .................................................................................................................. %
9. Schedule Of Hazards:
Loc.
No.
Classification Description
Class.
Code
Exposure
Premium Basis
(s) Gross Sales
(p) Payroll
(a) Area
(c) Total Cost
(t) Other
10. Has applicant been involved as a General Contractor in the building of Residential Homes,
Condominiums or Townhouses in the past ten (10) years? .................................................................
Yes No
If yes, indicate maximum number built during any twelve (12) month period, maximum at any one project/develop-
ment site and expected maximum number to be built during next twelve (12) months. (For these purposes a duplex is
equivalent to two single family residences; a triplex equals three homes, etc.)
No. Residential Homes
No. any one Project/
Development Site
No. Condominiums/
Townhouses
Next 12 months
Prior Year:
Prior Year:
Prior Year:
Prior Year:
Prior Year:
Prior Year:
Prior Year:
Prior Year:
Prior Year:
Prior Year:
11. Advise the maximum number of residential homesites developed in any one year or at any one project site
(past, present, future):
12. Does applicant have a formal home warranty program? ...................................................................... Yes No
If yes, provide details:
13. Does applicant have model homes? ....................................................................................................... Yes No
If yes, provide no.:
Location:
14. List all major projects completed within the past five years, including work in progress and planned projects.
(List project name, date, project description, location, and revenues):
GLS-APP-8s (10-13) Page 3 of 10
15. Operations By Applicant—Indicate percentage of payroll for each type of construction work performed by
applicant’s employees:
Airports
% Gas Mains %
Rooftop work (other than
roofing)
%
Asbestos Removal
% Insulation
% Sewer
%
Blasting
% Maintenance
% Soil Stabilization
%
Bridges/Elevated Roads
% Masonry
% Steel (ornamental)
%
Carpentry
% Mechanical
% Steel (structural)
%
Communication Lines
% Mold & Spore Remediation
% Street/Road/Highway
%
Concrete
% Oil or Gas Facilities
% Supervisory Only
%
Drilling
% Painting
% Swimming Pools
%
Earthquake Reinforce-
ment/ Retrofitting
% Pipeline/Water Main % Tunneling %
EIFS
% Plastering
% Underpinning
%
Electrical
% Plumbing
% Waterproofing
%
Excavating
% Power Lines
% Water Restoration
%
Fire Proofing
% Process Piping
% Wrecking/Demolition
%
Fire Restoration %
Removal/Installation of
Underground Tanks
%
Other (describe) %
Framing of Buildings
% Roofing
%
16. Subcontractors Operations Performed for Applicant—Indicate percentage of subcontracted work costs for all
construction work performed by applicant’s subcontractors:
Airports
% Gas Mains %
Rooftop work (other than
roofing)
%
Asbestos Removal
% Insulation
% Sewer
%
Blasting
% Maintenance
% Soil Stabilization
%
Bridges/Elevated Roads
% Masonry
% Steel (ornamental)
%
Carpentry
% Mechanical
% Steel (structural)
%
Communication Lines
% Mold & Spore Remediation
% Street/Road/Highway
%
Concrete
% Oil or Gas Facilities
% Supervisory Only
%
Drilling
% Painting
% Swimming Pools
%
Earthquake Reinforce-
ment/ Retrofitting
% Pipeline/Water Main % Tunneling %
EIFS
% Plastering
% Underpinning
%
Electrical
% Plumbing
% Waterproofing
%
Excavating
% Power Lines
% Water Restoration
%
Fire Proofing
% Process Piping
% Wrecking/Demolition
%
Fire Restoration %
Removal/Installation of
Underground Tanks
%
Other (describe) %
Framing of Buildings
% Roofing
%
GLS-APP-8s (10-13) Page 4 of 10
17. Account history for prior five years and projected current year:
Year Payroll Total Revenue
Subcontracted Cost
Cost of
Labor, Fees,
Commissions +
Cost of Materials
& Equipment
Rental =
Total
Subcontracted
Cost
Current $
$
$
$
$
1st Prior $
$
$
$
$
2nd Prior $
$
$
$
$
3rd Prior
$
$
$
$
$
4th Prior $
$
$
$
$
5th Prior $
$
$
$
$
18. Dollar value of average job completed: $
19. Subcontractors:
a. Are all subcontractors required to carry General Liability insurance? .................................................. Yes No
If yes, minimum General Liability limits required:............................................................................... $
b. Are all subcontractors required to carry Workers Compensation insurance? ...................................... Yes No
c. Are certificates of insurance obtained from all subcontractors? ........................................................... Yes No
d. Is applicant named as an additional insured on all subcontractors’ policies? ...................................... Yes No
e. Does applicant use uninsured subcontractors? .................................................................................... Yes No
If yes, percentage of total subcontracted cost: ...................................................................................... %
f. Do written contracts contain hold-harmless agreements in favor of the applicant? ............................. Yes No
If no, explain when not required:
g. Does applicant normally use the same subcontractors? ...................................................................... Yes No
If no, is subcontracted work put out for bids? ....................................................................................... Yes No
h. Does applicant own or operate a salvage yard and/or act as a secondhand building materials
dealer? ..................................................................................................................................................
Yes No
20. Any work performed in the past using Exterior Insulation and Finish Systems (EIFS)? .................. Yes No
If yes:
a. Any work on residential structures? ...................................................................................................... Yes No
b. Any work performed without drainage channels? ................................................................................. Yes No
c. Number of years experience with EIFS applications:
d. Any prior claims involving EIFS application? ........................................................................................ Yes No
If yes, provide details:
21. Indicate if any work done involving systems that provide:
Medical and/or industrial life support Process piping Dams/levees
22. Indicate if work requires monitoring by:
Certified inspectors Resident inspectors Part-time When called
23. Any work performed above two stories in height from grade? ............................................................ Yes No
If yes, maximum number of stories:
24. Any work performed below grade? ......................................................................................................... Yes No
If yes, maximum depth: ft. ......................................................................... % of total work
GLS-APP-8s (10-13) Page 5 of 10
25. Is scaffolding owned, rented or erected?
Are other contractors at job site allowed to use it? ...................................................................................... Yes No
26. Does applicant have a formal safety program in operation? ................................................................ Yes No
Explain and/or provide a copy:
27. Has applicant ever built or intend on building on hillsides, slopes, former landfills/dumps or in
subsidence areas? ....................................................................................................................................
Yes No
If yes, explain:
Percent of grade % Prior testing (geological, topical)? ............................................................. Yes No
If yes, explain:
Which geological survey engineering firm does applicant use?
Underpinning? ............................................................................................................................................. Yes No
Any past subsidence losses? ...................................................................................................................... Yes No
If yes, explain:
28. Any mobile equipment leased from others? .......................................................................................... Yes No
If yes, from whom?
Lease basis?
Operators provided? .................................................................................................................................... Yes No
Type of equipment leased?
29. Does applicant own any Vacant Land? (Raw land with no developmental or improvement activity,
held only for investment or possible development more than twelve (12) months in the future. No build-
ings on property.) .........................................................................................................................................
Yes No
If yes, property is zoned: Residential Commercial/Retail/Industrial Other:
No. of Acres No. of Lots Location Description
30. Does applicant own any Real Estate Development Property? (Land with improvements—streets,
roads, utilities, etc. completed or under construction) .................................................................................
Yes No
If yes, property is zoned: Residential Commercial/Retail/Industrial
If zoned residential, provide location descriptions and number of lots at each development.
No. of Acres No. of Lots Location Description
GLS-APP-8s (10-13) Page 6 of 10
31. Does applicant or any of applicant employees hold a Real Estate Agent’s license? ........................ Yes No
If yes, has Professional Liability Coverage been obtained? ........................................................................ Yes No
Limit of Liability: $
32. Does applicant hold other persons’ property for service, storage or repair? .................................... Yes No
If yes, explain:
33. Any underground storage tanks? ............................................................................................................ Yes No
If yes, when inspected and by whom?
34. Any employees working under:
U.S. Longshoremen’s and Harborworkers’ Act? ................................................................................... Yes No
Jones Maritime Act?.................................................................................................................................. Yes No
If yes, what percent of payroll? % Give city and state:
35. Does applicant have Workers’ Compensation coverage in force? ...................................................... Yes No
36. Does applicant lease employees from others? ...................................................................................... Yes No
Does applicant lease employees to others? ........................................................................................... Yes No
37. Are any operations insured elsewhere by an owner-controlled insurance program (OCIP), also
referred to as wrap insurance? ................................................................................................................
Yes No
If yes, provide details:
38
. List all active owners, partners and executive officers and their job duties/responsibilities:
39. 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:
40. Additional Insured Information:
Name Address Interest
41. Does applicant have other business ventures for which coverage is not requested? ...................... Yes No
If yes, explain and advise where insured:
42. During the past three years, has any company ever canceled, nonrenewed, declined or refused
similar insurance to the applicant? (Not applicable in Missouri) ............................................................
Yes No
If yes, explain:
GLS-APP-8s (10-13) Page 7 of 10
43. Prior Carrier Information:
Year:
Year:
Year:
Year:
Year:
Carrier
Policy No.
Total
Premium
$ $ $ $ $
44. Has applicant ever had a Construction Defect loss/claim or been involved in a class action Con-
struction Defect suit? ................................................................................................................................
Yes No
If yes, provide details of losses or suits older than five years:
Date of
Loss
Description of Loss
Amount
Paid
Amount
Reserved
Claim Status
(Open or
Closed)
$
$
$
$
$
$
$
$
$
$
45. Loss History—Five Year Period:
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. Check if no losses in the last five years.
Date of
Loss
Description of Loss
Amount
Paid
Amount
Reserved
Claim Status
(Open or
Closed)
$
$
$
$
$
$
$
$
$
$
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 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.
GLS-APP-8s (10-13) Page 8 of 10
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.
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 AUTOMOBILE FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance
company or other person files an application for commercial insurance or a statement of claim for any commercial or per-
sonal insurance benefits containing any materially false information, or conceals for the purpose of misleading, infor-
mation concerning any fact material thereto, and any person who, in connection with such application or claim, knowingly
makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, dam-
age or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or an insurance
company, 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 value of the subject motor vehicle or stated claim for each violation.
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.
GLS-APP-8s (10-13) Page 9 of 10
We hereby declare that the above statements and particulars are true and I/We agree that this application shall be the
basis of the contract with the insurance company.
APPLICANT’S NAME AND TITLE:
APPLICANT’S SIGNATURE: DATE:
(Must be signed by an active owner, partner or executive officer)
CO-APPLICANT’S SIGNATURE: DATE:
PRODUCER’S SIGNATURE: DATE:
AGENT NAME: AGENT LICENSE NUMBER:
(Applicable to Florida Agents Only)
IOWA LICENSED AGENT:
(Applicable in Iowa Only)
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-8s (10-13) Page 10 of 10
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

General ContractorsDevelopers 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