Fillable KINSALE Special Contractual Liab Application

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KINSALE Special Contractual Liab Application

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Page 1 of 4
SPECIAL CONTRACTUAL LIABILITY APPLICATION
COMPLETE IN ADDITION TO ACORD APPLICATIONS.
ATTACH ADDITIONAL SHEETS AS NECESSARY.
ANSWER ALL QUESTIONS. If not applicable, indicate N/A.
DATE:
APPLICANT’S NAME:
MAILING ADDRESS:
STREET ADDRESS (if different):
CITY, STATE, ZIP CODE:
YEARS IN BUSINESS:
WEBSITE: www.
1) 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:
2) Applicant’s business structure: Individual Partnership ”C” Corporation ”S” Corporation
LLC or LLP Other (describe)
3) State/area of operation:
4) Describe your operations:
5) Describe the product(s), project or situation which is the subject of this application:
APPLICANT’S INFORMATION
GENERAL INFORMATION
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 4
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
6) What percent of work will you subcontract to others? %
7) What will that work entail?
8) Do you usually have the same subcontractors? Yes No
9) Do you have a written contract with your subcontractors? Yes No
If yes, provide a copy.
10) Do you obtain certificates of insurance from all subcontractors prior to any work being Yes No
performed by them on your behalf?
11) How long do you retain those certificates?
12) Is work approved by written acceptance?
13) Prior Relevant Project History:
Customer
Project Description
Completion
Time
Covered By
Warranty (Y/N)
Warranty Claim
Presented? (Y/N)**
14) Prior product sales for products to which this application applies:
Product Trade Name
Product Description
Estimated
Annual Sales
% Covered by
warranty
Warranty claims
presented? (Y/N)**
** If you answered yes we require an explanation of those warranty claims including failure rates and causes, remedy
employed, time required to remedy claims, cost of remedy and steps taken to assess possible future claims and the result of
those assessments.
15) Do you do all field service and repair work? Yes No
16) Do you have a formal safety program? (Attach copy) Yes No
17) Do you have a formal QA/QC program? (Attach copy) Yes No
Page 3 of 4
18) Do your suppliers and subcontractors warrant their products or work? Yes No
If you answered “yes”, we require copies of those warranty documents and agreements.
19) During the past five years, has any insurer ever canceled or non—renewed similar coverage Yes No
to any applicant or has your coverage been canceled for non—payment of premium by any
insurance or finance company? If yes, please explain:
20) 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.
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.
Page 4 of 4
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:
FEIN #:
Applicant’s Signature: Date:
Agent/Broker Name:
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KINSALE Special Contractual Liab Application

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Completed 2 July 2020

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