Two Lincoln Centre, 5420 Lyndon B. Johnson Freeway, Suite 1100, Dallas, Texas 75240-2345
casualtysubmissions@hallmarkgrp.com
General Information:
Name Insured:
Contractors Supplemental Application
DBA:
Mailing Address:
State: Zip Code:
Individual
Entity is:
Corporations Partnership Other:
Describe:
Contractor's License Number and Type::
Owner
Applicant is:
General Contractor Construction Manager Other:
Describe:
Counties/Cities Do You Work In?
Years Operated Current Business? Total Years Experience as a Contractor?
Describe Your Operation:
Percentage of Typical Project Performed By Employees:
%
Work Breakdown:
%
New Residential Construction:
%
Residential Remodeling:
%
Office Construction:
%
Office Remolding:
%
Other:
%
Commercial:
%
Government/Institutional:
Describe:
No
R
With New Residential, Do You Work on More Than 5 Homes in One Subdivision?
Percentage of Typical Project Subcontracted:
%
Please Indicate Whether the Following Trades are Performed By Employees (R - Retained) or Performed By Subcontractors (S):
Bridge Construction:
S
R
Carpentry:
S
R
Concrete:
S
R
Debris Removal:
S
R
Drilling:
S
R
Drywall:
S
R
Electrical:
S
R
Excavation:
S
R
Framing:
S
R
Grading:
S
R
Guard Rail Install:
S
R
Interior Demolition:
S
R
Landscaping:
S
R
Masonry:
S
R
Painting:
S
R
Parking Lot Paving:
S
R
Plumbing:
S
R
Roofing:
S
R
Street Paving:
S
R
Stucco:
S
Hallmark E&S - Contractors Supplemental Application Page 1
Yes
No
With New and Remodeling Residential, Do You Work on Condominiums,
Townhomes, Cooperatives or Timeshares?
Yes
Hallmark E&S - Contractors Supplemental Application Page 2
No
Demolition - Other Than Interior:
Yes
Are Any of Your Operations Involved in the Following Special Hazards:
No
Asbestos Removal:
Yes
No
Blasting:
Yes
No
Caisson or Cofferdam Work:
Yes
No
Pile Driving:
Yes
No
Dams:
Yes
No
Use of Cranes:
Yes
No
Use of Tower Cranes:
Yes
Length of the Booms:
ft.
No
Other:
Yes
Describe Other:
No
Do You Perform Work More Than 2 Stories in Height Above Grade?
Yes
If Yes, What Percentage? Describe:
%
What is the Maximum Number of Stories in Structures Built?
No
Do You Perform Work Below Grade?
Yes
If Yes, What Percentage? Describe:
%
No
Is Job Site Security Provided at Night?
Yes
If Yes, Describe:
No
Have You Ever Built on Hillsides, Slopes, Landfills or Other Terrains Susceptible to Subsidence?
Yes
If Yes, Explain:
No
Do You Draw Any Plans or Blueprints Used in Your Construction Work?
Yes
If Yes, Describe:
No
Do You Carry "Professional Liability" or "Errors and Omissions" Insurance?
Yes
Subcontractors Exposure:
If You NEVER Hire Subcontractors, Please check here
. Please Skip to Part D.
No
Are All Subcontractors Required to Sign a Hold-Harmless or Indemnification Agreement in Your Favor?
Yes
No
Do You Utilize a Standardized Contract With All of Your Subcontractors?
Yes
If Yes, Please Attach a Copy to This Questionnaire.
No
Do You Require All Subcontractors to: Carry the Same or Greater Limits and Coverage?
Yes
No
Name You as Additional Insured?
Yes
No
Furnish Certificates of Insurance of General Liability?
Yes
No
Furnish Certificates of Insurance of Workers Compensation?
Yes
NoYes
Shoring or Underpinning:
NoYes
Airports:
NoYes
Bridge Work:
If Yes, Provide Carrier Name(s), Coverages, Policy Terms and Limit of Liability:
Hallmark E&S - Contractors Supplemental Application Page 3
Describe the 5 Largest Projects Undertaken in the Last 5 years:
Project #1: Job Cost: $ Duration:
Project #2: Job Cost: $ Duration:
Project #3: Job Cost: $ Duration:
Project #4: Job Cost: $ Duration:
Project #5: Job Cost: $ Duration:
Describe the 3 Largest Projects Planned for the Upcoming Year:
Project #1: Est Cost: $ Duration:
Project #2: Est Cost: $ Duration:
Project #3: Est Cost: $ Duration:
What is the Average Dollar Value of Each Project? $
Describe Types of Projects You Will Not Accept:
List Payroll of Owners, Supervisors, and Employees, Designated By Class and Duties Performed:
Class: Payroll: $ Duties:
Class: Payroll: $ Duties:
Class: Payroll: $ Duties:
Class: Payroll: $ Duties:
Class: Payroll: $ Duties:
No
Are You Involved in Any Additional Businesses Besides Contracting?
Yes
If Yes, Describe:
No
Has Any General Contractor and/or Subcontractor Contacted You Regarding a Problem With Your Work?
Yes
If Yes, Describe:
No
Have You Been Involved in Pending/Current Litigation Concerning Defective Workmanship?
Yes
If Yes, Describe:
Hallmark E&S - Contractors Supplemental Application Page 4
List Your Loss History For the Past 5 Years:
Year of Loss: Carrier: Coverage: # Losses:
$
Amount: Description of Losses:
$
$
No
Has Insurance Been Cancelled, Refused or Non-renewed By Any Company in the Past 3 Years?
Yes
If Yes, Describe:
NOTICE TO ALABAMA, ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, CONNECTICUT, DELAWARE, GEORGIA, IDAHO, ILLINOIS, INDIANA, IOWA,
KANSAS, MARYLAND, MASSACHUSETTS, MICHIGAN, MINNESOTA, MISSISSIPPI, MISSOURI, MONTANA, NEBRASKA, NEVADA, NEW
HAMPSHIRE, NORTH CAROLINA, NORTH DAKOTA, OREGON, RHODE ISLAND, SOUTH CAROLINA, SOUTH DAKOTA, TEXAS, UTAH, VERMONT,
WASHINGTON, WEST VIRGINIA, WISCONSIN, AND WYOMING APPLICANTS: In some states, 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, for
the purpose of misleading, conceals information concerning any fact material thereto, may commit a fraudulent insurance act which is a crime in
many states.
NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete or misleading facts or information 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 policyholder or claiming with regard to a
settlement or award payable for insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory
Agencies.
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING: 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 insurance company files a statement
of claim containing any false, incomplete or misleading information is guilty of a felony of the third degree.
NOTICE TO HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a
loss or benefit is a crime punishable by fines or imprisonment, or both.
FRAUD WARNING
List Your Risk Exposure History For the Past 5 Years:
Year: Carrier:
$
Payroll
$
$
$
Sales/Receipts
$
$
$
Sub-Contractor Costs
$
$
$$ $
$$ $
$
$
Hallmark E&S - Contractors Supplemental Application Page 5
NOTICE TO KENTUCKY APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance 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.
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 subject 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 denial of insurance benefits.
NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is
subject to criminal and civil penalties.
NOTICE TO NEW MEXICO 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 civil fines and criminal penalties.
NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud an 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 $5,000 and the stated value of the claim for each such violation.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he/she 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: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes a
any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
NOTICE TO PENNSYLVANIA APPLICANTS: Any person who knowingly and with intent to defraud any insurance company, or other person, files an
application for insurance or statement of a 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 the person to criminal and
civil penalties.
NOTICE TO TENNESSEE 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 include imprisonment, fines and denial of insurance benefits.
NOTICE TO VIRGINIA 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 include imprisonment, fines and denial of insurance benefits.
FRAUD WARNING (Continued)
IMPORTANT- The Applicant acknowledges that the answers provided herein are based on a reasonable inquiry and/or investigation. The Applicant
warrants that the above statements and particulars together with any attached or appended documents are true and complete and do not
misrepresent, misstate or omit any material facts.
The Applicant agrees to notify us of any material changes in the answers to the questions on this questionnaire which may arise prior to the
effective date of any policy issued pursuant to this questionnaire and the Applicant understands that any outstanding quotations may be modified
or withdrawn based upon such changes at our sole discretion.
Completion of this form does not bind coverage. Applicant's acceptance of the company's quotation is required prior to binding coverage and
policy issuance. All written statements and materials furnished to the company in conjunction with this application are hereby incorporated by
reference into this application and made a part of this application.
Applicant's Signature:
Date:
Please email the completed application to: casualtysubmissions@hallmarkgrp.com
Applicant: Title:
FEIN#:
Agent/Broker Name:
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