Fillable KINSALE Solar Energy Contractor Supplemental ARtisan Contractor Supplemental Application

Fill Online, Printable, Fillable, Blank KINSALE Solar Energy Contractor Supplemental ARtisan 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 Solar Energy Contractor Supplemental ARtisan Contractor Supplemental Application

On average this form takes 47 minutes to complete

The KINSALE Solar Energy Contractor Supplemental ARtisan Contractor Supplemental Application form is 6 pages long and contains:

  • 1 signature
  • 58 check-boxes
  • 155 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 6
SOLAR ENERGY CONTRACTOR SUPPLEMENTAL APPLICATION
COMPLETE IN ADDITION TO ACORD APPLICATIONS.
ATTACH ADDITIONAL SHEETS AS NECESSARY.
ANSWER ALL QUESTIONS. If not applicable, indicate N/A.
1. Applicant:
2. Mailing Address:
3. Years in business: Years of experience:
4. Web site: www.
5. Have you operated or are you operating under a different business name now or at any time Yes No
over the past 10 years? Provide details:
6. If new in business, years of prior experience and type of work performed:
7. Applicant works as a: General Contractor _______% Consultant _______%
Subcontractor _______% Owner/builder _______%
Construction Manager _______% Developer _______%
8. Are you licensed? Yes No Type of License? Year issued?
9. State/area of operation:
10. Describe your operations:
Current Year
1
st
2nd Prior Year
Prior Year
3
rd
4
Prior Year
th
Prior Year
Annual Gross Receipts
Employee Payroll
Cost of Subcontracted Work
# of employees
APPLICANT’S INFORMATION
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 6
Carrier:
Limit of Insurance:
Deductible:
Premium:
Expirations:
11. Please indicate type of work performed by your employees and your subcontractors:
Type of Work
Employees
Type of Work
Employees
Subcontractors
Consultation/Testing % % Manufacturing % %
Engineering/Design
%
Painting/Sandblasting
%
%
Equipment Distribution
%
Project Manager
%
%
Electricity Distribution % % Steel (structural) % %
Equipment/Supply Rental % % Site Preparation % %
Installation % % Supervisory only % %
Lessor Risk Only
%
Welding
%
%
Maintenance/Repair % % Other % %
If other, please explain:
12. Is any work being performed outside of the solar power industry? If yes, please describe:
_______
13. What percentage of operations is residential? _____ % What percentage of operations is commercial? _____ %
14. Any new residential work? Yes No
a. If yes, how much? _______________________________________________________________________
15. What percentage of panels will be ground-mounted? _____% Roof-mounted? _____%
16. Are any products that are being sold by the insured manufactured abroad? Yes No
a. If yes, from which countries? ______________________________________________________________
17. High Rise work is limited to a maximum of __________stories.
18. Does the Insured install, or contract to install, EIFS (Exterior Installation Finishing Systems)? Yes No
19. Does the Insured install, or contract to install, hardboard siding? Yes No
20. Does the insured install, remove or distribute drywall? Yes No
CURRENT CARRIER INFORMATION
BREAKDOWN OF OPERATIONS
Page 3 of 6
21. Do you install or service concentrating solar power (CSP) systems? Yes No
a. If Yes, which technologies are utilized?: _______Parabolic Troughs _______Stirling Dish
. _______Linear Fresnal Reflectors _______Solar Tower
_____ Other (please describe): ___________________________________________________________
22. Are you involved with passive solar construction? Yes No
a. If Yes, please check or describe all that apply _______Trombe Walls _______Barra System
_____Other (please describe): _____________________________________________________________
23. Which photovoltaic technologies are installed/serviced (check ALL that apply): ___Concentrating Photovoltaic (CVP)
_____Monocrystalline Silicon _____Polycrystalline Silicon _____Microcrystalline Silicon _____Thin Film
_____Cadmium Telluride _____Copper Indium Selenide _____Concentrator Modules _____Casting Wafers
_____ Other (please describe): ______________________________ ________________________________________
24. Length of power production warranty provided: ________________________________________________________
25. What is the minimum warranted power rating of the solar panels installed? __________________________________
26. What types of support brackets used for mounting? _____________________________________________________
27. Are these brackets fabricated by you or by others? ______________________________________________________
28. Do you install inverters with 60 Hz copper wound transformers? Yes No
a. What is the average production capacity of the systems installed?
___________________________________________________
29. Does the insured have any lessor’s risk solar installation? Yes No
If no, please skip to question #37.
30. Is the solar system in question already in place and functional? Yes No
31. What percentage of panels is ground-mounted? _____% Roof-mounted? _____%
32. Is the solar installation properly secured or fenced in? Yes No
33. Who is performing the operation of the system, if applicable? _______________________________________________
34. Who is performing the maintenance of the system? _______________________________________________________
35. How often is the system inspected? ____________________________________________________________________
36. Are proper agreements/risk transfer arrangements in place between the insured and the operations and maintenance
contractor? Yes
No
37. What percent of work do you subcontract to others? %
LESSOR’S RISK ONLY
SUBCONTRACTORS INFORMATION
Page 4 of 6
38. Do you usually use the same subcontractors? Yes No
39. Are subcontractors always insured? Yes No
40. What general liability limits do you require your subs to carry?
41. Are you named as an additional insured on all subcontractors’ policies?
42. Do you have a written contract with your subcontractors? If yes, provide a copy. Yes No
43. Do you obtain certificates of insurance from all subcontractors? Yes No
44. How long do you retain those certificates?
45. Have you allowed or will you allow your license to be used by any other contractor for Yes No
a project on which you have worked?
46. Has any other licensing authority taken any action against you? Yes No
Describe your last 5 projects Dollar Value
1.
2.
3.
4.
5.
Describe your 5 largest projects Dollar Value
1.
2.
3.
4.
5.
47. Does your organization perform any design or engineering services? Yes No
If yes, please describe: _______________________________________________________________________________
48. Do you have a formal safety program? Yes No
49. Does applicant use only components approved by the Solar Rating and Certification Yes No
Corporation (SRCC)?
50. Do you own or lease cranes? Yes No
51. Do you own or lease scaffolding? Yes No
52. Prior to any ground mounting or digging are you ensuring that all underground structures (utility lines, Yes No
cables, sewers, etc) are marked?
PRIOR PROJECTS
Page 5 of 6
53. During the past five years, has any insurer ever canceled or non—renewed similar insurance to Yes No
any applicant or has your insurance been canceled for non—payment of premium by any insurance
or finance company?
If yes, please explain:
54. Has any lawsuit ever been filed, or any claim otherwise been made against your company or Yes No
any 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 locations(s) of the
projects where such operations were performed. (Attach separate sheet if necessary.)
55. Is your company aware of any occurrences, facts, circumstances, incidents, situations, damages Yes No
or accidents (including but not limited to: allegations of faulty or defective workmanship, product
failure, construction dispute, property damage or construction worker 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 names(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.
COVERAGE HISTORY
Page 6 of 6
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.
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)
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 Solar Energy Contractor Supplemental ARtisan 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