Fillable OWNERS INTEREST APPLICATION (Philadelphia Insurance Companies)

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OWNERS INTEREST APPLICATION (Philadelphia Insurance Companies)

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OWNERS INTEREST APPLICATION
SECTION I – GENERAL INFORMATION
1.
Applicant’s Name:
2.
If the Applicant is a Limited Liability Company (LLC) please list the members of that LLC
3.
Any other requested named insured?
Yes
No
4.
If yes, please complete the following:
Note: The names provided are not automatically approved for Named Insured status. For
us to consider each entity we require, at minimum, the following:
a.
A role and function on the project which makes them applicable for Named Insured status.
b.
Receive full risk transfer, via contract, from all subcontractors on the project (hold harmless,
indemnification, and Additional Insured status).
Entity Name
Relationship to Primary
Named Insured
5.
Term of project:
6.
Project address(es):
7.
Scope of Work: (Provide details such as number of stories, structural/ nonstructural, renovation/
ground up, etc.)
8.
End use of the project: (i.e. condo, apartments, co-ops, office, etc.)
9.
Project hard costs:
(Please forward project budget – to include outline of both hard and soft costs)
10.
Additional project details:
a.
Is the use of a tower crane required for this project?
Yes
No
b.
Does the project require any addition to floors?
Yes
No
c.
How are sidewalks/ premises maintained?
(i.e. sidewalk maintenance, snow/ ice removal, etc.)
SECTION II – GENERAL CONTRACTOR
1. Provide the following information regarding the contractor being hired:
a. Name of selected general contractor:
b. General Liability carrier:
Owners Interest Questionnaire
Page 1 of 4
© 2020 Philadelphia Consolidated Holding Corp.
11/2020
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c.
Total General Liability and Excess Limits being required for this job:
d.
Does the contract with the selected general contractor provide hold harmless, indemnification,
and additional insured status to our Applicant?
Yes
No
e.
is the selected general contractor paying all the subcontractors on the project?
Yes
No
f.
is the selected general contractor contracting all the subcontractors on the project?
Yes
No
g.
is the selected general contractor supervising all the subcontractors on the project?
Yes
No
h.
other than the general contractor, will the Applicant hire any subcontractors directly?
Yes
No
if yes, please complete the following:
Name Of Subcontractor To
Be Hired Directly
What Work Will The
Subcontractor Be Hired To
Perform
Amount Of The Contract
The Subcontractor Will Be
Awarded
General Liability
Carrier For The
Subcontractor
SECTION III - OCCUPANCY
1.
Will there be any occupancy during the project term?
Yes
No
2.
Is coverage for the occupancy desired?
Yes
No
If yes, please complete the following:
a.
Type of Occupancy:
Commercial (provide details):
Residential
b.
Total number of occupied units:
Square footage:
c.
Any losses in the past five (5) years? (Please attach loss runs)
Yes
No
d.
Tenants and workers use separate entry/ stairwells?
Yes
No
e.
How are tenants protected from construction activities?
3.
What is in place at the location to protect its occupants from trespassers?
a.
Are there security personnel at the location?
Yes
No
b.
Is there a doorman or similar individual to check access credentials?
Yes
No
c.
Are there security cameras in place at the location?
Yes
No
d.
Is access to the building limited via keys or card access?
Yes
No
e.
Other (describe):
SECTION IV - DEMOLITION
1.
Will there be any demolition of exterior walls or roofs?
Yes
No
If yes, please complete the following:
a.
Name of demolition contractor:
b.
Total demolition costs:
c.
How long will demolition last?
d.
What entity is contracting with and signing contracts with the demolition contractor?
e.
Total GL and Excess Limits required for the demolition contractor?
f.
Demolition contractor general liability carrier?
g.
Provide safety precautions in place to protect pedestrians: (i.e. sidewalk closures, flagmen,
fencing, etc.)
Owners Interest Questionnaire
Page 2 of 4
© 2020 Philadelphia Consolidated Holding Corp.
11/2020
Clear Application
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SECTION V – PRIOR WORK
1.
Has any work been already completed on the project?
Yes
No
If yes, please complete the following:
a.
When did work start?
b.
What work has been completed to date?
c.
Total costs completed to date?
d.
Name of the general contractor who was responsible for the prior work completed?
e.
Name of GL carrier providing coverage for the Applicant during the prior work?
f.
Policy number of policy providing coverage for the Applicant during the prior work?
SECTION VI – INSPECTION CONTACT INFORMATION
1.
Contact name:
2.
Contact email:
3.
Contact phone number:
Owners Interest Questionnaire
Page 3 of 4
© 2020 Philadelphia Consolidated Holding Corp.
11/2020
Clear Application
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FRAUD STATEMENT AND SIGNATURE SECTIONS
The Undersigned states that he/she is an authorized representative of the Applicant and declares to the best of his/her knowledge and belief
and after reasonable inquiry, that the statements set forth in this Application (and any attachments submitted with this Application) are true
and complete and may be relied upon by Company * in quoting and issuing the policy. If any of the information in this Application changes
prior to the effective date of the policy, the Applicant will notify the Company of such changes and the Company may modify or withdraw the
quote or binder.
The signing of this Application does not bind the Company to offer, or the Applicant to purchase the policy.
*Company refers collectively to Philadelphia Indemnity Insurance Company and Tokio Marine Specialty Insurance Company.
FRAUD NOTICE STATEMENTS
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 AND SUBJECTS THAT PERSON TO
CRIMINAL AND CIVIL PENALTIES (IN OREGON, THE AFOREMENTIONED ACTIONS MAY CONSTITUTE A FRAUDULENT INSURANCE ACT WHICH MAY
BE A CRIME AND MAY SUBJECT THE PERSON TO PENALTIES). (IN NEW YORK, THE CIVIL PENALTY IS NOT TO EXCEED FIVE THOUSAND DOLLARS
($5,000) AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION). (NOT APPLICABLE IN AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN,
NM, OK, PA, RI, TN, VA, WA AND WV).
APPLICABLE IN AL, AR, AZ, DC, LA, MD, NM, RI AND WV: ANY PERSON WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS A FALSE OR
FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS FALSE INFORMATION IN AN
APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES OR CONFINEMENT IN PRISON.
APPLICABLE IN COLORADO: 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 POLICYHOLDER OR CLAIMANT FOR THE PURPOSE
OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM
INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY
AGENCIES.
APPLICABLE IN FLORIDA AND OKLAHOMA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER
FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A
FELONY (IN FL, A PERSON IS GUILTY OF A FELONY OF THE THIRD DEGREE).
APPLICABLE IN KANSAS: AN ACT COMMITTED BY ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE
PRESENTED 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 STATEMENT 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 CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO.
APPLICABLE IN KENTUCKY: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSONS
FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF
MISLEADING, INFORMATION CONCERNING ANY MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.
APPLICABLE IN MAINE, 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. PENALTIES MAY INCLUDE IMPRISONMENT,
FINES OR A DENIAL OF INSURANCE BENEFITS.
APPLICABLE IN PENNSYLVANIA: 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.
APPLICABLE IN VERMONT: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE STATEMENT IN AN APPLICATION FOR INSURANCE MAY BE GUILTY
OF A CRIMINAL OFFENSE AND SUBJECT TO PENALTIES UNDER STATE LAW.
APPLICABLE IN NEW YORK: 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 BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATE VALUE OF THE CLAIM FOR EACH
SUCH VIOLATION.
NAME (PLEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR EXECUTIVE
DIRECTOR)
____________________________________________________
SIGNATURE DATE
SECTION TO BE COMPLETED BY THE PRODUCER/BROKER/AGENT
PRODUCER AGENCY
(If this is a Florida Risk, Producer means Florida Licensed Agent)
PRODUCER LICENSE NUMBER
(If this a Florida Risk, Producer means Florida Licensed Agent)
ADDRESS (STREET, CITY, STATE, ZIP)
Owners Interest Questionnaire
Page 4 of 4
© 2020 Philadelphia Consolidated Holding Corp.
11/2020
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Completed 11 February 2021

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