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JANITORIAL PROGRAM GENERAL LIABILITY SUPPLEMENTAL APPLICATION (Colonial General Insurance Agency, Inc)

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GL-APP-13s (9-16) Page 1 of 4
JANITORIAL PROGRAM GENERAL LIABILITY SUPPLEMENTAL APPLICATION
(Complete in addition to the ACORD General Liability Application)
Applicant’s Name:
Location Address:
Agency Name:
Agent No.:
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)
1. Description of operations:
2. How long has applicant been in business? Full-time Part-time
3. Work performed is: Commercial: % Industrial: % Residential: %
4. Property Damage Extension limits (GLS-55s): (Cannot exceed General Liability Limits.)
$5,000 Occurrence/$25,000 Aggregate $50,000 Occurrence/$50,000 Aggregate
$10,000 Occurrence/$25,000 Aggregate $100,000 Occurrence/$100,000 Aggregate
$25,000 Occurrence/$25,000 Aggregate $250,000 Occurrence/$250,000 Aggregate
5. Employee Data Number Annual Payroll
Leased/Subcontracted Number Annual Cost
Owner(s) only $ Leased Employees $
Employees excluding clerical: Independent Contractors*
$
Full-Time
$ (*Include cost of uninsured subcontractors as employee payroll)
Part-Time
$
6. Does applicant subcontract any operations? ........................................................................................ Yes No
If yes:
a. Description of operations subcontracted:
b. Are all subcontractors required to carry General Liability and Workers Compensation Insurance? .... Yes No
If yes, minimum General Liability limits required:..................................................................................
c. Are certificates of insurance required from all subcontractors? ............................................................ Yes No
d. Is applicant included as an additional insured on all subcontractors’ policies? .................................... Yes No
e. Do written contracts contain hold-harmless agreements in favor of the applicant? ............................. Yes No
If no, explain when not required:
GL-APP-13s (9-16) Page 2 of 4
7. Indicate annual sales for each of the following serviced:
Operations for Annual Sales Operations for Annual Sales
Aircraft $ Industrial $
Apartments $ Offices $
Cleanrooms $ Offshore Oil Rigs $
Construction Make Ready $ Private Residences $
Convalescent/Nursing Homes and
Assisted Living Facilities
$ Retail Stores $
Convenience/Grocery Stores and
Supermarkets
$ Schools/Colleges/Universities $
Convention Halls/Centers $ Shopping Centers and Malls $
Crime Scene Cleanup $ Sports Arenas or Complexes $
Department/Discount Stores $ Transportation Terminals $
Hospitals $ Theaters $
Hotels $ Other (describe): $
Total Annual Sales
$
8. Indicate payroll and sales for each operation performed:
Operation Payroll Sales
Appliance loading, unloading or installation $ $
Carpentry $ $
Carpet/Upholstery Cleaning $ $
Construction Cleanup
Interior Exterior
$ $
Consulting $ $
Equipment Rental $ $
Fire/Water Restoration $ $
Floor Stripping/Waxing $ $
Janitorial—General Services $ $
Janitorial Supply Retail/Wholesale $ $
Landscaping/Plant or Shrub Servicing $ $
Machinery/Equip. Clean/Degreasing $ $
Meth Lab Cleanup $ $
Mold or Spore Remediation $ $
Painting $ $
Packing, loading or unloading operations $ $
Pressure Cleaning $ $
Recycling $ $
Sandblasting $ $
Sanitizing medical equipment or instruments $ $
Security $ $
Snow Removal $ $
Restaurant Vent Hood Cleaning $ $
Window/Screen/Skylight Cleaning $ $
Other (describe): $ $
GL-APP-13s (9-16) Page 3 of 4
9. Exterior window cleaning:
Maximum number of stories: ......................................................................................................................
Scaffolding/rigging: Rented Owned None
10. Any exterior work over three stories? ..................................................................................................... Yes No
11. Provide a brief description of any hazardous waste handled, storage of combustible material and recyclables
handled:
12. Are applicant’s employees bonded? ....................................................................................................... Yes No
If yes, effective date of coverage: ................................................................................................................
13. 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:
14. Does applicant have other business ventures for which coverage is not requested? ...................... Yes No
If yes, explain and advise where insured:
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 in AL, CO, DC, FL, KS, LA, ME, MD, MN, NE, NY,
OH, OK, OR, RI, TN, VA, VT or WA.)
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.
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 addi-
tion, an insurer may deny insurance benefits if false information materially related to a claim was provided by the appli-
cant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any insur-
er files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a fel-
ony of the third degree.
NOTICE TO KANSAS APPLICANTS: Any person who, knowingly and with intent to defraud, presents, causes to be pre-
sented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any
agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of an in-
surance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance pol-
icy for commercial or personal insurance which such person knows to contain materially false information concerning any
fact material thereto; 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.
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.
GL-APP-13s (9-16) Page 4 of 4
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 un-
der 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 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 a civil penalty not to exceed five thousand dollars and the stated value of the claim
for each such violation.
APPLICANT’S STATEMENT:
I have read the above application and I declare that to the best of my knowledge and belief all of the foregoing statements
are true, and that these statements are offered as an inducement to us to issue the policy for which I am applying. (Kan-
sas: This does not constitute a warranty.)
APPLICANT’S NAME AND TITLE:
APPLICANT’S SIGNATURE: DATE:
(Must be signed by an owner, partner or executive officer)
PRODUCER’S SIGNATURE: DATE:
Agent Email:
Preferred Method of Correspondence Email Fax Mail
Applicant Email:
Preferred Method of Correspondence Email Fax Mail
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.
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JANITORIAL PROGRAM GENERAL LIABILITY SUPPLEMENTAL APPLICATION (Colonial General Insurance Agency, Inc)

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Completed 22 August 2020

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