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MACHINERY AND EQUIPMENT SUPPLEMENTAL APPLICATION (Colonial General Insurance Agency, Inc)

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GLZ-APP-89s (9-16) Page 1 of 5
Scottsdale Insurance Company
Home Office: One Nationwide Plaza
Columbus, Ohio 43215
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
Scottsdale Indemnity Company
Home Office: One Nationwide Plaza
Columbus, Ohio 43215
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
Scottsdale Surplus Lines Insurance Company
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
MACHINERY AND EQUIPMENT SUPPLEMENTAL APPLICATION
(Complete in addition to the ACORD General Liability Application)
Applicant’s Name:
Location Address:
Agency Name:
Agent No.:
Phone No.:
PROPOSED EFFECTIVE DATE: From To 12:01 A.M., Standard Time at the address of the Applicant
ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE” (N/A)
1. Annual Employee Payroll: ....................................................................................................................... $
2. Number of Active Owners/Officers: ........................................................................................................
3. Annual Receipts: ...................................................................................................................................... $
4. Annual Subcontractors Cost: .................................................................................................................. $
5. How many years in business? ................................................................................................................ Years
How many years of experience? ................................................................................................................ Years
6. Specify the last five projects (or top five clients, if new venture) with the client/industries being served and
specific types of machinery being serviced:
1.
2.
3.
4.
5.
7. Are all service technicians factory certified or trained under an apprenticeship or trade school? Yes No
If no, describe:
8. Percentage of operations performed:
In Shop % Off-Site/Mobile % Off-Shore % Installation Operations %
Describe off-site operations:
GLZ-APP-89s (9-16) Page 2 of 5
9. Indicate any past, present or discontinued services in any of the following:
Aircraft or aerospace applica-
tions/unmanned aircraft
Amusement devices
(mechanical)
ATM equipment
ATVs/UTVs
Boat lifts
Bottling plant equipment
Caissons
Chemical industry equipment
Contractors equipment
Conveyors equipment
Cotton pickers
Cranes
(length of boom
ft.)
Electrical power generating
equipment
Elevators/escalators/moving
sidewalks
Exercise and fitness equipment
Farm machinery
Feed mills
Forklifts
Garage or auto repair
equipment
Gas/natural gas/oil/LPG
production
Gasoline pump equipment
Generators
Grain elevators/silos/bins
Hog equipment
Hydraulics or hoists
Industrial valves or pumps
Ladders or lift equipment
(other than forklifts)
Lawn and garden equipment
Logging/lumbering equipment
Medical equipment
Military equipment
Mining equipment
Nuclear power plant equipment
Pipeline work involving
gas/natural gas/oil/LPG
Playground equipment
Pollution control
Poultry equipment
Pressure vessels/tanks/boilers
Printing press equipment
Railroad equipment
Rigging equipment
Robotics
Safety guards or equipment
Sawmill equipment
Textile equipment
Tree stands
Watercraft, boats or ships
Wood chippers
Other (describe):
If any of the above categories are checked, describe in more detail client industries being served and specific
type of equipment
:
10. Is applicant involved in rigging operations? .......................................................................................... Yes No
If yes, provide gross sales:
11. Does applicant install new equipment in factories? .............................................................................. Yes No
If yes, how many years of experience:
12. Is applicant involved in the manufacturing, sales, service or repair of 3D printers? ........................ Yes No
13. Does applicant perform any computer design, programming or consulting services? .................... Yes No
If yes, describe with the percentage of operations declared:
14. Does applicant fabricate or machine any equipment or component parts? ....................................... Yes No
If yes, explain:
15. Does applicant act as a machinery dealer or wholesaler? ................................................................... Yes No
If yes, provide detail with annual sales declared:
16. Does applicant have a written quality control program in place? ........................................................ Yes No
GLZ-APP-89s (9-16) Page 3 of 5
17. Does applicant subcontract work to others? ......................................................................................... Yes No
If yes:
Are certificates of insurance obtained? ....................................................................................................... Yes No
Is applicant named as an additional insured on all subcontractors’ policies? ............................................. Yes No
Do subcontractors provide hold harmless agreements in favor of the applicant? ...................................... Yes No
18. Hold-Harmless Agreements:
Does applicant use a standard client contract, which outlines the specific responsibilities of the
applicant? ....................................................................................................................................................
Yes No
Do others hold applicant harmless? ............................................................................................................ Yes No
Does applicant agree to hold any third party harmless? ............................................................................. Yes No
Does applicant assume, by contract or verbally, responsibility for any injury or damage that may
occur? .......................................................................................................................................................... Yes No
19. Does applicant have Workers’ Compensation coverage in force? ...................................................... Yes No
Does applicant lease employees? ............................................................................................................... Yes No
20. Does risk engage in the generation of power, other than emergency back-up power, for their
own use or sale to power companies?....................................................................................................
Yes No
If yes, describe:
21. Does applicant have any other business ventures for which coverage is not requested? ............... Yes No
If yes, explain and advise where insured:
This application does not bind the applicant nor the Company to complete the insurance, but it is agreed that the infor-
mation contained herein shall be the basis of the contract should a policy be issued.
FRAUD WARNING: 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 conceals for the purpose of
misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and
subjects such person to criminal and civil penalties. (Not applicable in AL, CO, DC, FL, KS, LA, ME, MD, MN, NE, NY,
OH, OK, OR, RI, TN, VA, VT or WA.)
NOTICE TO ALABAMA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to restitution fines or confinement in prison, or any combination thereof.
NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or in-
formation 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 policy holder or claimant with regard to a settlement or award pay-
able from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory
Agencies.
WARNING TO DISTRICT OF COLUMBIA APPLICANTS: 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 addi-
tion, an insurer may deny insurance benefits if false information materially related to a claim was provided by the appli-
cant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any insur-
er files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a fel-
ony of the third degree.
GLZ-APP-89s (9-16) Page 4 of 5
NOTICE TO KANSAS APPLICANTS: Any person who, knowingly and with intent to defraud, presents, causes to be pre-
sented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any
agent thereof, any written, electronic, electronic impulse, facsimile, magnetic, oral, or telephonic communication or state-
ment as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or
commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal
insurance which such person knows to contain materially false information concerning any fact material thereto; or con-
ceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act,
which is a crime and subjects such person to criminal and civil penalties.
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 sub-
ject 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 a denial of
insurance benefits.
NOTICE TO MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent claim for
payment of a loss or benefit or who knowingly or willfully 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 MINNESOTA APPLICANTS: A person who files a claim with intent to defraud or helps commit a fraud
against an insurer is guilty of a crime.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he 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: Any person who knowingly, and with intent to injure, defraud or deceive any
insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading infor-
mation is guilty of a felony.
NOTICE TO RHODE ISLAND 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.
FRAUD WARNING (APPLICABLE IN VERMONT, NEBRASKA AND OREGON): Any person who intentionally presents
a materially false statement in an application for insurance may be guilty of a criminal offense and subject to penalties un-
der state law.
FRAUD WARNING (APPLICABLE IN TENNESSEE, VIRGINIA AND WASHINGTON): It is a crime to knowingly provide
false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penal-
ties include imprisonment, fines, and denial of insurance benefits.
NEW YORK AUTOMOBILE FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance
company or other person files an application for commercial insurance or a statement of claim for any commercial or per-
sonal insurance benefits containing any materially false information, or conceals for the purpose of misleading, infor-
mation concerning any fact material thereto, and any person who, in connection with such application or claim, knowingly
makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, dam-
age or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or an insurance
company, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed
five thousand dollars and the value of the subject motor vehicle or stated claim for each violation.
GLZ-APP-89s (9-16) Page 5 of 5
NEW YORK OTHER THAN AUTOMOBILE FRAUD WARNING: 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 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 five thousand dollars
and the stated value of the claim for each such violation.
APPLICANT’S NAME AND TITLE:
APPLICANT’S SIGNATURE: DATE:
(Must be signed by an active owner, partner or executive officer)
PRODUCER’S SIGNATURE: DATE:
AGENT NAME: AGENT LICENSE NUMBER:
(Applicable in Florida Agents Only)
IOWA LICENSED AGENT:
(Applicable in Iowa Only)
IMPORTANT NOTICE
character, general reputation, personal characteristics and mode of living. Upon written request, additional information
as to the nature and scope of the report, if one is made, will be provided.
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Completed 22 August 2020

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