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POOL AND SPA CONTRACTOR SUPPLEMENTAL (Philadelphia Insurance Companies)

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POOL AND SPA CONTRACTOR SUPPLEMENTAL
SUBMISSION REQUIREMENTS
• Completed ACORD applications
• Completed signed / dated PHLY supplemental
• Currently valued insurance company loss runs for the current policy period plus four (4) years
• Copy of contract currently used with any / all sub-contractors
• Copy of contract between insured and customer
SECTION I - ACCOUNT INFORMATION
Applicant’s Name:
Any DBAs or other subsidiaries?
Yes
No
Phone:
Risk Manager:
Risk Manager Email:
Business Type:
Sole Proprietor
C-Corporation
S-Corporation
Partnership
Date Established:
Years of Experience:
SECTION II – GENERAL INFORMATION
1.
Memberships:
APSP (List Regions):
NESPA
FSPA
Master Guild (List States):
Other:
2.
Number of Employees:
Full Time:
Part Time:
Seasonal:
3.
Percentage of Applicant’s work for the below categories to include all work performed by the
Applicant and/ or sub-contractor:
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:
%
4.
List the states the Applicant has worked in during the last five years:
5.
Any operations in New York state?
Yes
No
If yes, please provide detailed description of all operations including any non-pool construction
operations:
6.
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):
%
$
%
$
%
$
Pool and Spa Contractor Supplemental
Page 1 of 7
© 2018 Philadelphia Consolidated Holding Corp.
02/2018
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Services
Percent of Services
Sales
Retails stores
%
$
Wholesale distribution
%
$
Other operations i.e. holiday decorations, etc. (describe
and provide % and sales of each):
%
$
%
$
%
$
7.
Does the Applicant have any other operations other than those described above?
Yes
No
If yes, please describe:
8.
Payroll
Sub-Contractor Costs
Gross Receipts
Next 12 months
$
$
$
1
st
Prior Year
$
$
$
2
nd
Prior Year
$
$
$
3
rd
Prior Year
$
$
$
4
th
Prior Year
$
$
$
9.
Please list the five largest projects in the past five (5) years.
1.
2.
3.
4.
5.
SECTION III – OPERATIONS
1.
Does the Applicant have a formal written safety program which is reviewed with all employees and
sub-contractors?
Yes
No
2.
Does the Applicant have a quality controls program?
Yes
No
3.
Does the Applicant conduct worksite inspections?
Yes
No
4.
Does the Applicant document the precise location and layout of any underground utility lines, as
well as any working or defunct on-site septic systems of cesspools, and / or any municipal water
and sewer lines that run through the property before construction begins?
Yes
No
5.
Does the Applicant have a written accident investigation program?
Yes
No
6.
Does the Applicant comply with the Association of Pool & Spa Professionals (APSP) minimum
standards of pool installation / service?
Yes
No
7.
Is the Applicant a Certified Building Professional (CBP) per APSP standards?
Yes
No
8.
Does the Applicant follow ANSI-APSP-7 standards to identify suction entrapment hazards on ALL
projects?
Yes
No
9.
Do warnings about the potential risks of shallow water diving also appear in all printed materials for
pool buyers, such as owners’ manuals or pool instruction and care booklets?
Yes
No
10.
What recommendations does the Applicant make to customers with regard to perimeter fencing,
especially around in-ground pools?
11.
Before any site work begins on in-ground pools, does the installer ensure that all required
documentation has been filed and the necessary permits obtained?
Yes
No
12.
Are pool depth markers a requirement for all installations to be installed at all venues (commercial
or residential)?
Yes
No
If no, does the Applicant require the customer to sign a form or waiver indicating that he or she has
been informed about the safety benefits of depth markers but has opted out to have them?
Yes
No
13.
Any past, current, or planned installations of pools for the developer of a homeowners
associations, condo or tract housing community?
Yes
No
14.
Are pool designs signed off by customer and records maintained for at least seven (7) years?
Yes
No
15.
Does the Applicant current have Professional Liability coverage (Construction E&O) in place?
Yes
No
Pool and Spa Contractor Supplemental
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02/2018
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16.
Any current or future plans to work on hillsides, in landfills, or areas subject to subsidence?
Yes
No
If yes, please list precautions taken:
17.
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
18.
Is the Applicant actively licensed in the state(s) it operates to perform the work that is undertaken?
Yes
No
19.
Does the Applicant test the soil at the jobsite for soil types and proper compacting before
excavating?
Yes
No
20.
Does the Applicant have drainage guidelines to prevent pool “pop-up”?
Yes
No
21.
Any installation of diving boards over one (1) meter high, water slides or climbing walls?
Yes
No
If yes, please describe:
22.
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
23.
Any pool, hot tub, or spa installation on roof tops?
Yes
No
24.
Does the Applicant have retail sales of chemicals?
Yes
No
If yes, list products and average quantity stored on premises:
25.
Does the Applicant manufacture any pool chemicals for sale under its name or other products with
its own name on the label?
Yes
No
26.
Where are all chemicals or hazardous materials stored at the worksite?
27.
Are all of the Applicant’s pool chemicals stored in closed, EPA-approved containers?
Yes
No
28.
What training do employees receive in the proper handling of pool chemicals and the disposal of
chemically treated pool water?
29.
Does the Applicant import any foreign products?
Yes
No
Percent of Sales: %
30.
Have there been any Virginia Graeme Baker Pool and Spa compliance related issues?
Yes
No
If yes, please provide description:
31.
Have there been any pollution related losses in the last five (5) years?
Yes
No
32.
Does the Applicant sell wood stoves?
Yes
No
If yes, does the Applicant use a working display of a wood stove?
Yes
No
33.
Does the Applicant offer in-house financing for customers who are purchasing its products?
Yes
No
If yes, how and where is confidential information stored?
34.
Do all pool designs require a dual drain system (i.e. with two separate drain outlets) preventing a
vacuum seal if one outlet is blocked?
Yes
No
35.
Does the Applicant erect a temporary fence around all work sites, excavated or not?
Yes
No
Are warning signs and barricades set up?
Yes
No
36.
Please describe any warranty provided in relation to installation of the pool or spa:
37.
Any current or past involvement with a commercial or industrial wrap-up/OCIP/CCIP?
Yes
No
38.
Any current or past involvement with a residential or habitational wrap-up/OCIP/CCIP?
Yes
No
Pool and Spa Contractor Supplemental
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© 2018 Philadelphia Consolidated Holding Corp.
02/2018
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SECTION IV - SUB-CONTRACTORS
1.
Does the Applicant use sub-contractors?
Yes
No
If yes, please complete the following:
a.
Percentage of the Applicant’s work sub-contracted out:
%
Annual Costs: $
b.
Nature of work sub-contracted:
c.
Does the Applicant’s written agreement with sub-contractors contain indemnification and/ or
hold harmless wording in the Applicant’s favor?
Yes
No
d.
Are sub-contractors 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 sub-contractor’s General Liability
policies?
Yes
No
f.
Does the contract require the sub-contractor 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 sub-contractor’s CGL insurance 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”.
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 V - AUTO
N/A
1.
Does the Applicant have a fleet safety and vehicle maintenance program?
Yes
No
2.
Any personal use of vehicles?
Yes
No
If yes, please describe:
3.
Does the Applicant perform a pre-hire review of Motor Vehicle Records (MVR’s) on prospective
employees and then annually thereafter?
Yes
No
4.
How does the Applicant handle employees with unacceptable driving records? (warning,
probationary period, etc.)
5.
Does the Applicant have a driver accident points system in place?
Yes
No
6.
Does the Applicant have a formal driving policy in place with MVR standards?
Yes
No
If yes:
a.
Is driving policy communicated in writing to all employees?
Yes
No
b.
Is a signed acknowledgement form kept on file?
Yes
No
If yes, please provide a copy of signed acknowledgement.
c.
Do driving standards include the following:
i.
No major violations including DUI, racing, hit and run, speeding in excess of 20 mph over
posted speed limit, manslaughter?
Yes
No
ii.
No more than 2 moving violations within past 3 years?
Yes
No
iii.
No more than 1 at fault accident within past 3 years?
Yes
No
7.
How often does the Applicant check MVR reports?
8.
Does the Applicant allow any newly hired drivers to operate vehicles without going through a
company-specific documented driver training?
Yes
No
Pool and Spa Contractor Supplemental
Page 4 of 7
© 2018 Philadelphia Consolidated Holding Corp.
02/2018
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9.
Describe any ongoing training provided to drivers:
10.
Does the Applicant have GPS tracking capability?
Yes
No
11.
Does the Applicant allow employees to drive personal vehicles for company purposes?
Yes
No
If yes:
a.
Are the driving policy and standards for these drivers the same as in questions 1-3?
Yes
No
b.
Does the Applicant require these employees to have adequate personal insurance limits?
Yes
No
SECTION VI – INLAND MARINE
N/A
1.
Does the Applicant lease or rent equipment from others?
Yes
No
If yes:
a.
What is the maximum value of any single item: $
b.
What is the annual rental expense: $
c.
Do all operators receive proper training prior to taking possession of the equipment?
Yes
No
d.
Is the equipment secured to prevent theft with keys removed when not in use?
Yes
No
2.
Does the Applicant have materials at job sites which they care to have installation floater coverage
for?
Yes
No
If yes:
a.
Please select a limit desired:
$5,000
$10,000
$15,000
$20,000
Other: $
b.
Are the materials the Applicant desires coverage for theirs or in their care, custody and
control?
Yes
No
c.
Are materials secured on site to prevent theft?
Yes
No
If yes, what controls are in place?
3.
Does the Applicant desire coverage for their small tools?
Yes
No
If yes:
a.
What limit is desired ($1,000 max single item)?
b.
What controls are in place to prevent theft of the Applicant’s small tools?
4.
Does the Applicant use a crane within their operations?
Yes
No
If yes:
a.
What is the boom length?
b.
Does the Applicant rent the crane?
Yes
No
If yes, is the crane rented with an operator?
Yes
No
Pool and Spa Contractor Supplemental
Page 5 of 7
© 2018 Philadelphia Consolidated Holding Corp.
02/2018
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SECTION VII - 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 Supplemental
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02/2018
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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
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 Supplemental
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02/2018
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