Fillable Joint Venture Supplemental Application (Kinsale Insurance)

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Joint Venture Supplemental Application (Kinsale Insurance)

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The Joint Venture Supplemental Application (Kinsale Insurance) form is 3 pages long and contains:

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  • 10 check-boxes
  • 42 other fields

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Page 1 of 3
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
JOINT VENTURE SUPPLEMENTAL COVERAGE APPLICATION
a. Name of Joint Venture:
b. Joint Venture Project Description and Location:
c. Services Performed by Applicant:
d. Services Performed by Others:
e. Is Applicant’s portion of the Joint Venture currently insured?: Yes No
Carrier: Limit Deductible
Name and Address
a. Yes No Carrier
b. Yes No Carrier
c. Yes No Carrier
d. Has any claim ever been made against you or against any Joint Venture member with regard to the project
named in question No. 1 above? Yes
No If yes, please attach detailed description.
a. Fees and Construction Values:
(i) Total Construction Values of Joint Venture: $
(ii) Gross Fees for Joint Venture (all members): $
(iii) Your Share of Gross Fees for Joint
Venture:________%
(iv) Your Fees: Estimate for coming year:*
(from ______ to___________) $
Latest 12 months: (from _____to______) $
Previous 12 months: (from ____ to ____) $
*Those fees apply to Joint Venture ONLY
b. Duration of Joint Venture:
(i) Date of Preliminary Design through Completion of Design:
Beginning of Preliminary Design ____/____/______
(MM/DD/YYYY)
% of design completed ______%
Completion date ____/____/______
(MM/DD/YYYY)
APPLICANT’S INFORMATION
OTHER PARTIES TO JOINT VENTURE AND THEIR INSURANCE
JOINT VENTURE
Page 2 of 3
(ii) Construction Dates: Beginning: ____/____/______ (MM/DD/YYYY)
Ending: ____/____/______
(MM/DD/YYYY)
(iii) Percentage of Joint Venture Completed: _____%
c. Former Joint Ventures:
If coverage for completed Joint Ventures is desired, please provide a list of these using same format as above
and INCLUDING information on previous coverage for these Joint Ventures.
FRAUD WARNING
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.
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.
Page 3 of 3
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.
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: Title:
(Must be signed by a Principal, Partner, or Officer of the Firm)
Applicant’s Signature: Date:
Agent/Broker Name:
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Joint Venture Supplemental Application (Kinsale Insurance)

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Completed 15 July 2020

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