Fillable Government Service Contactor Application 09.19 (All Risks, Ltd)

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Government Service Contactor Application 09.19 (All Risks, Ltd)

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Government Service Contractor Application 09.19 Page 1 of 4
ALL RISKS, LTD. – National Specialty Programs
10150 York Road, 5
th
Floor, Hunt Valley, MD 21030
Toll Free: 800- 366-5810
•
Fax: 410- 828-8179
Contact us: programs@allrisks.com
www.allrisks.com
Government Service Contactor Application
General Information (Complete All Lines)
1. First Named Insured: ________________________________________________________________________________________
Additional DBA Names: ______________________________________________________________________________________
2. Physical Address: ___________________________________________________________________________________________
Street Name City/County/State/Zip
3. Mailing Address: ___________________________________________________________________________________________
Street Name City/County/State/Zip
4. Insured Email Address: ______________________________________________________________________________________
5. Inspection Contact: _________________________________________ Phone: ____________________________
Audit Contact: _________________________________________ Phone: ____________________________
Claims Contact: _________________________________________ Phone: ____________________________
6. Telephone: ____________________________ 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. Provide the names of your five (5) largest revenue producing clients, and type of facility:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
12. Do you subcontract work? Yes No
If yes, do you require certificates and/or proof of Errors & Omissions and Commercial General Liability
Insurance? Yes No
13. Training Program consists of: Written Manual On Job CPR Report Writing
Powers of Arrest Films Firearms Classroom
Other: _____________________________________________________________
Government Service Contractor Application 09.19 Page 2 of 4
14. Pre-employment screening procedures consist of:
Polygraph Prior Employer Contacted Criminal Background Drug Screening
Fingerprint Check Driving Record Psychological Test Personal References
Other: _________________________________________
15. Do you anticipate using dogs? *Must be leashed not to exceed 6ft. Yes No
If yes, number of dogs used with handlers: ____________________ Without handlers: __________________
What purpose will the dogs be used? Bombs Drugs Airports
Other: _________________________
16. Please complete 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: _____________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
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
Government Service Contractor Application 09.19 Page 3 of 4
CURRENT GENERAL LIABILITY INFORMATION
1. Please provide names of carriers, premiums paid, limits, sales, deductibles, and loss runs for the past 5 years.
Year
Year
Year
Year
Year
Carrier
Premium
Payroll
Hours
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 insured ever had a lapse in coverage? Yes No
If yes, please explain: ___________________________________________________________________________________
CLAIM INFORMATION
1. Please be sure to attach 5 years of currently valued loss runs. (Valued no more than 3 months from date of application)
2. Do you require staff to report all unusual incidents and are all incident reports reviewed by Management? Yes No
3. Do you have any knowledge concerning any incidents that have occurred prior to the date of this application
which may give rise to a future claim? Yes No
ALL RISKS, LTD.
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 MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE
ACT, WHICH IS A CRIME BY SIGNING THIS APPLICATION, THE SIGNOR WARRANTS THAT TO THE BEST KNOWLEDGE ALL NFORMATION
GIVEN IS TRUE AND ACCURATE.
___________________________________ ___________________________________ _____________________
Insured Name (type or print) Insured Signature Date
NOTICE TO PRODUCERS: THE PRODUCER HEREBY WARRANTS THAT THE INFORMATION CONTAINED IN THIS APPLICATION IS TRUE
AND CORRECT TO THE BEST OF HIS/HER KNOWLEDGE.
_______________________________ _______________________________ _________________ ______________
Producer Name (Type or Print) Producer Signature Date License #
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Government Service Contractor Application 09.19 Page 4 of 4
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. Who is responsible for safety? __________________________________________________________________________
WC WAIVER OF SUBROGATION
Blanket Individual
Please provide the names, addresses and class codes/payroll of all contracts requiring an individual waiver of subrogation.
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
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Government Service Contactor Application 09.19 (All Risks, Ltd)

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Completed 15 July 2020

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