Fillable KINSALE CN New-York-Contractors-Supplemental-Application - NY KINSALE Contractors Supplemental Application

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KINSALE CN New-York-Contractors-Supplemental-Application - NY KINSALE Contractors Supplemental Application

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Page 1 of 7
NEW YORK CONTRACTOR’S SUPPLEMENTAL APPLICATION
COMPLETE IN ADDITION TO ACORD APPLICATIONS.
ATTACH ADDITIONAL SHEETS AS NECESSARY.
ANSWER ALL QUESTIONS. If not applicable, indicate N/A.
1. Name of Applicant:
Individual Corporation Partnership Other (Explain)
Address:
2. Date Business Began: Years of Experience:
3. Website: www.
4. Have you operated or are you operating under a different business name now or at any Yes No
time over the past 10 years? (If Yes, provide details.)
5. Applicant works as a:
General Contractor % Consultant %
Subcontractor % Owner/Builder %
Construction Manager % Developer %
6. Are you licensed? Yes No License #
Please provide a copy of the license. A quote cannot be issued until a copy of the contractor’s license is received.
7. Cities and counties in which you operate:
8. Describe your operations:
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 7
9. Please complete the following chart:
Estimated Sales for
Next 12 Months
1
st
Prior Year
2
nd
Prior Year
3
Prior Year
4
th
Prior Year
Annual Gross Receipts
Employ
ee Payroll
Cost of Subcontracted
Work
10. Percentage of work that has been and will be performed by you or on your behalf:
A. Residential ______________ % + Commercial/Industrial______________% = 100%
B. New ___________________ % + Repair/Remodel ______________% = 100%
C. Interior _________________ % + Exterior ______________% = 100%
New Construction: Single Family – Tract _________%
Single Family – Custom _________%
Condo/Townhome/Townhouse _________%
Commercial (Including Apartments) _________%
Other:________________________ _________%
Total = 100%
Repair & Remodeling: Single Family – Tract _________%
Single Family – Custom _________%
Condo/Townhome/Townhouse _________%
Commercial (Including Apartments) _________%
Other:________________________ _________%
Total = 100%
11. Indicate type of work that has been and will be performed by your employees:
Airport Runways
%
Grading
%
Sewers
%
Blasting
%
HVAC
%
Shee
t Metal
%
Bridge Building
%
Insulation
%
Steel (Ornamentation)
%
Carpentry
%
Landscaping
%
Steel (Structural)
%
Concrete
%
Maintenance
%
Street/Road Construction
%
Demolition
%
Masonry
%
Supervisory Only
%
Drilling
%
Mechanical
%
Traffic
Control
%
Dr
y Wall
%
Painting
%
Tunneling
%
Electrical
%
Plastering
%
Water Mains
%
Excavating
%
Plumbing
%
Waterproofing
%
Fire Suppression
%
Roofing
%
Windows/Doors
%
Gas Mains
%
Seismic Retrofit
%
Other
%
Page 3 of 7
12. Indicate type of work that has been and will be performed by your subcontractors:
Airport Runways
%
Grading
%
Sewers
%
Blasting
%
HVAC
%
Sheet Metal
%
Bridge Building
%
Insulation
%
Steel (Ornamentation)
%
Carpentry
%
Landscaping
%
Steel (Structural)
%
Concrete
%
Maintenance
%
Street/Road Cons
truction
%
Demolition
%
Masonry
%
Supervisory Only
%
Drilling
%
Mechanical
%
Traffic
Control
%
Dry Wall
%
Painting
%
Tunneling
%
Electrical
%
Plastering
%
Water Mains
%
Excavating
%
Plumbing
%
Waterproofing
%
Fire Suppression
%
Roofing
%
Windows
/Doors
%
Gas Mains
%
Seismic Retrofit
%
Other
%
13. What percentage of work do you subcontract to others? ___________%
Do you usually use the same subcontractors? Yes No
Are subcontractors always insured? Yes No
Do you obtain certificates of insurance from all subcontractors? Yes No
What general liability limits do you require your subs to carry?
Are you named as an additional insured on all subcontractors’ policies? Yes No
Do you have a written contract with your subcontractors? Yes No
Do all contracts contain a Hold Harmless clause in your favor? Yes No
Do you use any leased employees? Yes No
If yes, are you responsible for providing Worker’s Compensation for these employees? Yes No
Do you carry Worker’s Compensation insurance? Yes No
14. Have you allowed or will you allow your license to be used by any other contractor for a project on Yes No
which you have worked?
15. Has any other licensing authority taken any action against you? Yes No
16. Describe your last 5 projects:
Description
Dollar Valu
e
1.
2.
3.
4.
5.
Page 4 of 7
17. Describe your 5 largest projects:
Description
Dollar Value
1.
2.
3.
4.
5.
18. Are you or your subcontractors involved in projects where removal of hazardous materials, Yes No
asbestos, lead-based paints or chemical contamination is required?
If Yes, please provide details.
19. Do you perform repairs of fire, water or mold damage? Yes No
20. Do you have a formal safety program? Yes No
21. Do you provide a watchman or security at job sites? Yes No
22. Are sites fenced? Yes No
Lighted? Yes No
23. Do you own or rent cranes? Yes No
If Yes, What types of cranes? _____________________________________________________
If rented, are they rented with or without an operator? ________________________________
24. What precautions are taken to protect the public from injury?
Cones Yes No
Signs Yes No
Area Roped Off Yes No
Other Yes No
25. During the past five years, has any insurer ever canceled or non-renewed similar insurance to any Yes No
applicant or has your insurance been canceled for non-payment of premium by any insurance or
finance company?
If Yes, please explain.
26. Has any lawsuit ever been filed, or any claim otherwise been made against your company or any Yes No
partnership or joint venture of which you have been a member or your company’s predecessors in
business, or against any person, company or entities on whose behalf your company has performed
operations or assumed liability? For the purpose of this application only, a claim means a receipt of a
demand for money, service or arbitration.
If Yes, please explain including the name(s) of the person, company or entity and the name(s) and
location(s) of the projects where such operations were performed. (Attach a separate sheet if necessary.)
Page 5 of 7
27. Is your company aware of any occurrences, facts, circumstances, incidents, situations, damages or Yes No
accidents, (including but not limited to allegations of faulty or defective workmanship, product
failure, construction dispute, property damage or construction work injury) at a location or project
where your company has performed operations that a reasonably prudent person might expect to
give rise to a claim or lawsuit whether valid or not which might directly or indirectly involve the
company?
If Yes, please explain including the name(s) and location(s) of the projects where such operations
were performed. (Attach a separate sheet if necessary.)
Page 6 of 7
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.
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.
Page 7 of 7
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:
FEIN #:
Applicant’s Signature: Date:
Agent/Broker Name:
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Completed 2 July 2020

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