Fillable PORTABLE TOILET, SEPTIC SYSTEM, VACUUM TRUCK, & TREATMENT (Kinsale Insurance)

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PORTABLE TOILET, SEPTIC SYSTEM, VACUUM TRUCK, & TREATMENT (Kinsale Insurance)

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Page 1 of 6
PORTABLE TOILET, SEPTIC SYSTEM, VACUUM TRUCK, & TREATMENT FACILITY
SUPPLEMENTAL APPLICATION
COMPLETE IN ADDITION TO ACORD APPLICATIONS. ATTACH ADDITIONAL SHEETS AS NECESSARY.
ANSWER ALL QUESTIONS AND SIGN APPLICATION. INCOMPLETE APPLICATIONS WILL NOT BE CONSIDERED FOR COVERAGE.
If not applicable, indicate N/A.
1)
Named Insured:
Brokerage/Broker:
Agency/Agent:
Renewal? Yes No
Policy Number:
Effective Date:
Website:
2) Current Carrier Information:
Coverage
Carrier
Limit of
Insurance
Deductible
Premium
Retroactive
Date
General Liability
Contractors Pollution
Liability
Pollution Legal Liability
Non-Owned
Disposal Sites
Transportation Pollution
Professional Liability
(E&O)
Mold Liability
Please attach copies of the following:
a) Currently valued five year loss runs, including claim detail for all losses open or exceeding $15,000
b) Applicant’s product brochures or catalog if a website is not available
GENERAL INFORMATION
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 6
3) Mailing Address:
City: State: Zip Code:
4) Your premise address (if different from above):
City: State: Zip Code:
5) Requested Coverages:
Contractor’s Pollution Liability General Liability
Mold Liability Transportation Pollution Liability
Pollution Legal Liability from a Covered Location Professional Services Liability
Non-Owned Disposal Site Coverage
6) During the past three years, has the applicant had any coverage non renewed, cancelled Yes No
or declined? If yes, explain:
7) Limits Requested: $500,000/$500,000 $1,000,000/$1,000,000
$1,000,000/$2,000,000 Other:
8) Deductible Requested: $1,000 $2,500 $5,000
$10,000 $25,000 Other: $
9) History and Projections:
Estimated Upcoming Year Current Year Prior Year
Gross Annual Receipts
Employee Payroll
Cost of Subcontracted Work
Number of Employees
10) Please describe your operations:
11) Are subcontractors used? If no, skip to the next section. Yes No
12) Are all subcontractors licensed? Yes No
13) Please list subcontracted services and applicable cost:
SUBCONTRACTING INFORMATION
Page 3 of 6
14) Is a standard written contract used with clients and subcontractors using a limitation Yes No
of liability clause and hold harmless clause? (Please provide a copy.)
15) Are subcontractors required to have pollution liability insurance? Yes No
If required by trade only, please identify trades:
16) Does your firm collect certificates of insurance from all subcontractors? Yes No
How long do you retain those certificates?
17) Are you named as an additional insured on all subcontractors’ policies? Yes No
18) How often and under what circumstances will you use uninsured subcontractors?
19) What general liability limits do you require your subcontractors to carry?
20) Does your contract require that your subcontractors have a Waiver of Subrogation Yes No
endorsement in your favor on their General Liability and Worker’s Compensation policies?
21) Does your firm have written health and safety procedures? Yes No
If yes, please provide a copy of the table of contents.
22) Is your firm a member of the Portable Toilet Association International (PSAI)? Yes No
23) What percentage of your business is:
Residential: % Commercial: % Other: %
24) Please describe any operations or services that have been discontinued, sold, or abandoned, or any operations that
have been acquired.
25) Is the applicant providing any new services not provided last year? Yes No
If yes, please provide details.
26) Transportation/Disposal of Material:
Transported by applicant? Yes No
Transportation by independent hauler? Yes No
Disposal to Sanitary Sewer? Yes No
Disposal to Incinerator? Yes No
Applied to Land? Yes No
Wastes liquid or solid? Liquid Solid
Treatment on site or off site? On site Off site
SERVICES
Page 4 of 6
27) Please provide expected revenue for all applicable services you perform:
Expected Revenue Expected Revenue
Tank Pumping Portable Toilet Rental
Septic System Inspections Vacuum Truck
Septic System
Service/Maintenance
Tank/Drain Field
Installation/Excavation
Clean Grease Traps Land Application of Material
Excavation Plumbing
Other: Other:
28) Do you rent portable toilets? If no, skip to next section. Yes No
29) How many toilets do you own?
Standard: Handicapped/ADA: Special Amenity:
30) How are the portable toilets secured during transit?
31) Are your employees trained on proper toilet placement and stabilization at the Yes No
designated locations?
32) Does the applicant own, operate, or lease a treatment, storage, or disposal facility? Yes No
If yes, provide the facility specifics below. If no, skip to next section.
Brief Description of Operations
Historical Operations
33) Are the locations listed above required to be permitted and/or licensed? Yes No
If yes, please provide the permit numbers.
34) Are all of the locations listed above currently in compliance with federal, state, and Yes No
local regulations? If not, please describe.
35) Have any of these locations received a violation? Yes No
If yes, please provide details.
PORTABLE TOILET SERVICES
TREATMENT FACILITY
Page 5 of 6
36) Have you ever had a claim or complaint for noxious odors? Yes No
If yes, please describe.
37) Do you sell the processed material as fertilizer? Yes No
If yes, who applies the material?
38) Please describe any claims that have occurred in the last five years.
39) At the time of signing this application, are you aware of any circumstances that may Yes No
reasonably be expected to give rise to a claim under this policy? If so, please provide
details.
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.
CLAIMS HISTORY
Page 6 of 6
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.
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:
(Must be signed by a Principal, Partner, or Officer of the Firm)
FEIN #:
Applicant’s Signature: Date:
Agent/Broker Name:
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PORTABLE TOILET, SEPTIC SYSTEM, VACUUM TRUCK, & TREATMENT (Kinsale Insurance)

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Completed 31 January 2021

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