Fillable Janitorial Program General Liability Supplemental Application (RT Specialty)

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Janitorial Program General Liability Supplemental Application (RT Specialty)

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The Janitorial Program General Liability Supplemental Application (RT Specialty) form is 4 pages long and contains:

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  • 16 check-boxes
  • 158 other fields

Country of origin: US
File type: PDF

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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
Janitorial Program General Liability Supplemental Application
(Complete in addition to ACORD General Liability Application)
Name of Applicant:
Web site Address:
Location Address:
ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE.”
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:
GLS-APP-13s (4-12) Page 1 of 4
Submit Here
7. Indicate annual sales for each of the following serviced:
Operations for Annual Sales Operations for Annual Sales
Aircraft $
Industrial $
Apartments $
Offices $
Construction Make-Ready $
Off-shore Oil Rigs $
Convalescent/Nursing Homes &
Assisted Living Facilities
$ Private Residences $
Convenience/Grocery Stores &
Supermarkets
$ Retail Stores $
Convention Halls/Centers $
Schools/Colleges/Universities $
Crime Scene Cleanup $
Shopping Centers & Malls $
Department/Discount Stores $
Sports Arenas or Complexes $
Hospitals $
Transportation Terminals $
Hotels $
Theaters $
Other (describe):
$
Total Annual Sales $
8. Indicate payroll and sales for each operation performed:
Operation Payroll Sales
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 $
$
Pressure Cleaning $
$
Recycling $
$
Sandblasting $
$
Security $
$
Snow Removal $
$
Restaurant Vent Hood Cleaning $
$
Window/Screen/Skylight Cleaning $
$
Other (describe):
$
$
GLS-APP-13s (4-12) Page 2 of 4
9. Exterior window cleaning:
Maximum number of stories:
Scaffolding/rigging: Rented Owned None
10. Provide a brief description of any hazardous waste handled, storage of combustible material, and recyclables
handled:
11. Are applicant’s employees bonded? ....................................................................................................... Yes No
If yes, effective date of coverage:
12. 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:
13. 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 Nebraska, Oregon and Vermont.
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
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
insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a
felony in 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 and willfully presents a false or fraudulent claim for
payment of a loss or benefit or who knowingly and 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.
GLS-APP-13s (4-12) Page 3 of 4
NOTICE TO OHIO APPLICANTS: Any person who knowingly and with intent to defraud any insurance company 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.
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 Tennessee, Virginia and Washington): It is a crime to knowingly provide false, in-
complete or misleading information to an insurance company for the purpose of defrauding the company. Penalties in-
clude imprisonment, fines and denial of insurance benefits.
NOTICE TO NEW YORK APPLICANTS (Other than automobile): 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 NAME AND TITLE:
APPLICANT’S SIGNATURE: __________________________________________________________________ DATE:
(Must be signed by an owner, partner or executive officer)
PRODUCER’S SIGNATURE: DATE:
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-13s (4-12) Page 4 of 4
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Janitorial Program General Liability Supplemental Application (RT Specialty)

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Completed 13 December 2020

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