Fillable KINSALE EIFS Supplemental Application

Fill Online, Printable, Fillable, Blank KINSALE EIFS Supplemental Application Form

Use Fill to complete blank online KINSALE INSURANCE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

KINSALE EIFS Supplemental Application

On average this form takes 14 minutes to complete

The KINSALE EIFS Supplemental Application form is 4 pages long and contains:

  • 1 signature
  • 39 check-boxes
  • 33 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Kinsale Insurance forms online.

BROWSE KINSALE INSURANCE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Page 1 of 4
EIFS CONTRACTOR
SUPPLEMENTAL APPLICATION
COMPLETE IN ADDITION TO ACORD AND CONTRACTORS SUPPLEMENTAL APPLICATIONS
ATTACH ADDITIONAL SHEETS AS NECESSARY.
.
ANSWER ALL QUESTIONS. If not applicable, indicate N/A.
1. Name of Applicant:
Individual Corporation Partnership Other (Explain)
2. Date business began: Years of Experience installing EIFS systems:
3. 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.)
4. Please check all that apply:
New Commercial Construction
Residential repair/removal
New Residential Construction
Multi-family/condo repair/removal
New multi family/condo Installations over frame substrate
Commercial repair/removal Installations over masonry or steel substrate
Other (Describe):
5. Are you licensed? Yes No Type of License? Year Issued?
6. State/area of operation:
7. Which EIFS system manufacturers have trained and approved your firm to install their products?
8. Do you have a standardized installation and quality control manual? Yes No
9. Do you “mix and match” different manufacturers products on one job? Yes No
10. What percentage of the time do you install drainable systems? _______________%
GENERAL INFORMATION
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 4
11. Do you perform post-installation inspections to document changes made by others (i.e. signs, lighting) Yes No
12. Which trade associations do you belong to?
13. What percentage of EIFS work do you subcontract to others? %
14. How do you determine if subs are approved installers?
15. Do you usually use the same subcontractors? Yes No
16. What general liability limits do you require your subs to carry?
17. Are you named as an additional insured on all subcontractors’ policies? Yes No
18. Do you have a written contract with your subcontractors? Yes No
If Yes, please provide a copy.
19. Do you obtain certificates of insurance from all subcontractors? Yes No
20. How long do you retain those certificates?
21. 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?
22. What is the greatest number of new homes you have worked on in any one year?
When was that work done?
23. 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.
24. 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.)
25. 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?
Page 3 of 4
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.)
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 4 of 4
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:
Applicant’s Signature: Date:
Agent/Broker Name:
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

KINSALE EIFS Supplemental Application

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 2 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document