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POOL AND SPA CONTRACTOR RENEWAL SUPPLEMENTAL (Philadelphia Insurance Companies)

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POOL AND SPA CONTRACTOR RENEWAL SUPPLEMENTAL
SECTION I - ACCOUNT INFORMATION
1.
Applicant’s Name:
2.
Any DBAs or other subsidiaries?
Yes
No
3.
Phone:
Website: www.
4.
Risk Manager:
Risk Manager Phone:
Risk Manager Email:
5.
Number of Employees:
Seasonal:
6.
Percentage of Applicant’s work for the below categories to include all work performed by the
Applicant and/ or subcontractor:
Residential/ Habitational Pool & Spa Construction Work:
%
Residential/ Habitational Pool & Spa Service and Repair Work:
%
Non-Residential/ Habitational Pool & Spa Construction Work:
%
Non-Residential/ Habitational Pool & Spa Service and Repair Work:
%
7.
List the states the Applicant has worked in during the last five years:
8.
Any operations in New York state?
Yes
No
If yes, please provide detailed description of all operations including any non-pool construction
operations:
9.
Services
Percent of Services
Payroll
Installation of above-ground pools
%
$
Installation of in-ground pools
%
$
Installation of indoor pools
%
$
Installation of hot tubs and/ or spas
%
$
Service/ Cleaning/ Maintenance of pools & spas
%
$
Repair/ Rehabilitation of pools & spas
%
$
Snow plowing
%
$
Other operations i.e. plastering, hardscaping/
landscaping, etc. (describe and provide % and payroll of
each):
%
$
%
$
%
$
Services
Percent of Services
Sales
Retails stores
%
$
Wholesale distribution
%
$
Other operations i.e. holiday decorations, etc. (describe
and provide % and sales of each):
%
$
%
$
%
$
10.
Does the Applicant have any other operations other than those described above?
Yes
No
If yes, please describe:
Pool and Spa Contractor
Renewal Supplemental
Page 1 of 4
© 2019 Philadelphia Consolidated Holding Corp.
06/2019
Clear Application
Print Application
SECTION II – OPERATIONS
1.
Does the Applicant have a formal written safety program which is reviewed with all employees and
subcontractors?
Yes
No
2.
Does the Applicant have a quality controls program?
Yes
No
3.
Does the Applicant conduct worksite inspections?
Yes
No
4.
Any past, current, or planned installations of pools for the developer of a homeowners
associations, condo or tract housing community?
Yes
No
5.
Any current or future plans to work on hillsides, in landfills, or areas subject to subsidence?
Yes
No
If yes, please list precautions taken:
6. Any past, current, or planned involvement in: (check all that apply)
Blasting activities Removal or work on fuel tanks or pipelines Building of retaining walls
7. Is the Applicant actively licensed in the state(s) it operates to perform the work that is undertaken? Yes No
8. Does the Applicant do any installation or service work for water-parks, theme parks or amusement
parks currently or within the last five (5) years?
Yes No
9. Any pool, hot tub, or spa installation on roof tops? Yes No
10. Does the Applicant manufacture any pool chemicals for sale under its name or other products with
its own name on the label?
Yes No
SECTION III - SUBCONTRACTORS
1.
Does the Applicant use subcontractors?
Yes
No
If yes, please complete the following:
a.
Percentage of the Applicant’s work subcontracted out:
%
Annual Costs: $
b.
Nature of work subcontracted:
c. Does the Applicant’s written agreement with subcontractors contain indemnification and/ or
hold harmless wording in the Applicant’s favor?
Yes No
d. Are subcontractors required to carry the following minimum limits: General Liability of
$1,000,000 Occurrence, $2,000,000 General Aggregate, $2,000,000 Products/ Completed
Operations Aggregate; Workers’ Compensation (state statutory requirements); and
Commercial Automobile of $1,000,000?
Yes No
e. Does the Applicant obtain a certificate of insurance being listed as an additional insured
through the term of the contract, and subsequent to the completion of the contract, through the
appropriate jurisdiction’s statute of repose on the Applicant’s subcontractor’s General Liability
policies?
Yes No
f. Does the contract require the subcontractor to impose the same contractual risk transfer and
insurance obligations upon any sub-tier hired parties?
Yes No
g.
Does the contract specify the general aggregate for the subcontractor’s CGL ins
urance policy
IS to be made available on a “per project or location basis”, and prohibits “wasting” (or
“defense with limits”) policies?
Yes No
h. Does the contract require “additional insured” status be afforded by way of CGL endorsement
equivalent to ISOs 10 01 forms that include an “arising out of your ongoing operations” trigger,
or earlier versions that provide even broader coverage, rather than the current ISO 04 13
forms with the trigger “caused in whole or part”.
Yes No
i. Does the Applicant contract with a licensed electrician for all electrical work, or does it have
one on staff who performs all the necessary wiring during the installation process?
Yes No
SECTION IV - AUTO
N/A
1.
Does the Applicant have a fleet safety and vehicle maintenance program?
Yes
No
2.
Does the Applicant perform a pre-hire review of Motor Vehicle Records (MVR’s) on prospective
employees and then annually thereafter?
Yes
No
3.
How does the Applicant handle employees with unacceptable driving records? (warning,
probationary period, etc.)
4. Does the Applicant have GPS tracking capability? Yes No
Pool and Spa Contractor
Renewal Supplemental
Page 2 of 4
© 2019 Philadelphia Consolidated Holding Corp.
06/2019
Clear Application
Print Application
SECTION V - WINTER WEATHER FREEZE-UP PROTECTION
ONLY APPLICABLE IF INSURED OWNS A BUILDING / STOREFRONT
This section must be completed by all risks that have a location in one of the following states: AR, CT, DC, DE,
GA, IL, IN, KY, ME, MD, MA, MI, MO, NH, NY, NJ, NC, OH, PA, RI, SC, TN, TX, VT, VA, WV, WI
1.
Fire Protection and Testing
a.
Is the building provided with an Automatic Fire Sprinkler System (AS)?
Yes
No
N/A
i.
If yes, approximately what percentage (%) of the building is sprinklered?
%
ii.
If yes, what type of sprinkler system is installed?
Wet-Pipe
Dry-Pipe
Both
iii.
If yes, when possible, is the sprinkler piping primarily run within conditioned
areas designed to ensure the temperature remains above the 45°F minimum
temperature?
Yes
No
N/A
1.
If no, please describe freeze prevention measures (e.g. temperature
monitoring, heat trace, full insulation on piping or roof):
iv.
If yes, is the testing & inspection by qualified sprinkler contractor completed
within past 12 months & includes a formal winterization review?
Yes
No
N/A
v.
If yes, are the alarms tied to a 24 hour UL listed monitoring company?
Yes
No
N/A
2.
Emergency Water Response (domestic and AS water lines)
a.
Are water shutoff valves (domestic and AS water lines) marked and readily
accessible?
Yes
No
N/A
b.
Are water shutoff valves exercised (closed and reopened) at least annually?
Yes
No
N/A
c.
Is the staff qualified to respond and shut off the water main during normal business
hours and off hours?
Yes
No
N/A
3.
Automatic Water Shutoff Devices
a.
For domestic water lines, is there a water flow detection, notification and automatic
shutoff?
Yes
No
N/A
4.
Unused/Vacant Spaces
a.
Does Applicant have a formal process to turn off and drain domestic water lines for
these spaces?
Yes
No
N/A
5.
Unheated Areas (attics, crawl spaces, exterior wall joists)
a.
Are all domestic water lines located in areas heated to at least 45°F?
Yes
No
N/A
i.
If no, please describe freeze prevention measures (e.g. temperature monitoring,
heat trace, full insulation):
6.
General Comments:
Pool and Spa Contractor
Renewal Supplemental
Page 3 of 4
© 2019 Philadelphia Consolidated Holding Corp.
06/2019
Clear Application
Print Application
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
VIRGINIA APPLICANT: READ YOUR POLICY. THE POLICY OF INSURANCE FOR WHICH THIS APPLICATION IS BEING MADE, IF ISSUED,
MAY BE CANCELLED WITHOUT CAUSE AT THE OPTION OF THE INSURER AT ANY TIME IN THE FIRST 60 DAYS DURING WHICH IT IS IN
EFFECT AND AT ANY TIME THEREAFTER FOR REASONS STATED IN THE POLICY.
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, VT, 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 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)
Pool and Spa Contractor
Renewal Supplemental
Page 4 of 4
© 2019 Philadelphia Consolidated Holding Corp.
06/2019
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POOL AND SPA CONTRACTOR RENEWAL SUPPLEMENTAL (Philadelphia Insurance Companies)

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