Fillable KINSALE Roofing Contractor Supplemental Application

Fill Online, Printable, Fillable, Blank KINSALE Roofing Contractor 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 Roofing Contractor Supplemental Application

On average this form takes 26 minutes to complete

The KINSALE Roofing Contractor Supplemental Application form is 5 pages long and contains:

  • 1 signature
  • 26 check-boxes
  • 89 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 5
ROOFING CONTRACTOR’S SUPPLEMENTAL APPLICATION
COMPLETE IN ADDITION TO ACORD APPLICATIONS.
ATTACH ADDITIONAL SHEETS AS NECESSARY.
ANSWER ALL QUESTIONS. If not applicable, indicate N/A.
APPLICANT’S NAME:
MAILING ADDRESS:
STREET ADDRESS (if different):
CITY, STATE, ZIP CODE:
CONTACT PERSON: PHONE NUMBER:
Note: RESIDENTIAL means single-family dwellings, multi-family dwellings, condominiums, townhomes, townhouses,
apartments and cooperatives.
1. Indicate the percentage of work to be performed by you or on your behalf by subcontractors during the next twelve
months:
Residential ______________________% + Commercial/Industrial _____________________ % = 100%
2. Indicate the percentage of work performed by you or on your behalf by subcontractors during the past five years:
Residential ______________________% + Commercial/Industrial _____________________ % = 100%
3. Indicate the percentage of RESIDENTIAL work to be performed by you or on your behalf by subcontractors:
Single-Family Dwellings
%
Condominiums, Townhomes and Townhouses
%
Apartments and Cooperatives
%
TOTAL =
100%
APPLICANT’S INFORMATION
GENERAL INFORMATION
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 5
4. Indicate the percentage of RESIDENTIAL ROOFING work that is:
New construction %
TYPE OF ROOF WORK PERCENTAGE
Repair/patching % Hot tar %
Replacement % Tile %
TOTAL = 100% Shingles %
On pitched roofs? % Slate %
On flat roofs % Metal %
TOTAL = 100% Single Ply %
Other (describe)_____________ %
TOTAL = 100%
5. Indicate the percentage of COMMERCIAL/INDUSTRIAL ROOFING work that is:
New construction %
TYPE OF ROOF WORK PERCENTAGE
Repair/patching % Hot tar %
Replacement % Tile %
TOTAL = 100% Single Ply %
On pitched roofs % EPDM %
On flat roofs % Shingles %
TOTAL =
100%
Built Up
%
PVC %
Metal
Other (describe)_____________ %
TOTAL = 100%
6. Check work done other than roofing: Waterproofing Siding Asbestos removal Rain gutters
Carpentry Insulation EIFS/Synthetic Stucco Other (describe):
7. Describe the work performed on your behalf by subcontractors including the cost for each category:
Page 3 of 5
8. Provide exposure history for the past three years and your estimates for the next 12 months:
YEAR DIRECT LABOR PAYROLL AMOUNT PAID TO SUBS GROSS REVENUES
NEXT 12 MONTHS
9. Are all subcontractors hired under a standard written subcontractor’s agreement? Yes No
(attach a copy)
10. What are the standard insurance requirements for your subcontractors?
11. Are certificates of insurance collected from all subcontractors? Yes No
How long are they retained?
12. Provide details if you rent cranes or other equipment from others – including whether rented with or without operator –
and the corresponding cost of such rentals:
13. Indicate the number of cranes you own or lease long-term from others (please attach schedule).
14. If hot tar is used or torch work is performed, explain in detail the process and safety precautions used to prevent fires
during and after work hours:
15. Indicate the percentage of work to be performed involving the use of torches: _________%
Is all such work performed by employees certified by the National Roofing Contractors Association Yes No
or a similar industry organization?
16. Explain the precautions used to prevent weather infiltration:
17. Indicate the height of buildings on which you perform work: Average: _____ stories Maximum: _____ stories
18. Explain your employee fall-protection procedures:
19. Indicate the number of employees who are: Union _________ Non-Union ________
20. Indicate the average wage of your hourly workforce: ____________ per hour
21. Do you employ casual or temporary labor? Yes No
If yes, are such workers covered by your Workers Compensation insurance? Yes No
Page 4 of 5
22. Do you hire employees or independent contractors through employment agencies? Yes No
If yes, who is responsible for maintaining Workers Compensation insurance for such workers?
23. Are the employment agencies responsible for performing background checks on such Yes No
workers including verification of United States citizenship, valid Green Cards or valid Work Visas?
24. Indicate the number of job supervisors and foremen you employ:
25. Are all jobs inspected by a job supervisor or foreman upon completion of work but before Yes No
leaving the job site? If yes, please explain in detail:
26. Are you a member of the National Roofing Contractors Association? Yes No
Membership Identification #:
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.
Page 5 of 5
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.
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:
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 Roofing Contractor 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