Fillable Plowing Program Supplemental Application Snow (Risk Placement Services, Inc.)

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Plowing Program Supplemental Application Snow (Risk Placement Services, Inc.)

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  • 25 check-boxes
  • 118 other fields

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Page 1 of 4
Snow
Plowing Program Supplemental Application
(Complete in addition to the ACORD Application)
Applicant’s Name:
Mailing Address:
Location Address:
NEW BUSINESS RENEWAL
Agency Name:
Agent:
Address:
E-mail:
Phone No.:
PRO
POSED EFFECTIVE DATE:
From To 12:01 A.M., Standard Time at the address of the Applicant
ANSW
ER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE” (N/A)
Applicant is: Individual Corporation Partnership Joint Venture
Limited Liability Company Other (Specify)
Website Address:
E-mail Address: Phone Number:
Audit Contact Name:
E-mail Address: Phone Number:
1. Limit of Liability Desired:
2. Years of Snow Removal Experience:
3-Year Averages Can be Used for the Following:
3.
Annual Receipts from Snow & Ice Removal Operations:
$
Annual Payroll from Snow & Ice Removal Operations:
$
Annual Subcontractors Cost from Snow & Ice Removal Operations:
$
Annual Receipts from ALL Contracting Operations:
$
Annual Payroll from ALL Contracting Operations:
$
Page 2 of 4
Che
ck Off All That Apply for Snow Plowing Operations:
4.
Convenience Stores
Gas Stations
Big Box Stores
(ex Home Depot)
Pharmacies
Large Grocery Stores
Stadiums
Hardware Stores
Large Office Parks
Airports
24-Hour Locations
Banks with ATM’s
Hospitals
Medical Office Buildings
Governmental
Nursing Homes / Assisted Living
Single Family Homes: # of Homes:
(any o ne loc)
Lis
t Below All Commercial Snow Plowing Accounts
(attach list if necessary)
5.
Job Description / Location
Nature of Work
Job Cost
$
$
$
$
6.
Indicate the percentage of receipts in
categories below: (Column should total 100%)
Indicate the type and number of customers in the categories
below:
Snow Plowing/ Shoveling
%
Single Family Residential
# of Customers:
Snow Carting (off site)
%
Manufacturing Facilities
# of Customers:
Salting/Ice Treatment
%
Office / Business Parks
# of Customers:
Roof Raking /Ice Dam Removal %
Multi-family, Condo/Townhouse/
Apartment Complexes
# of Customers:
Other (describe):
%
Commercial Strip Malls, Banks,
Medical Offices & Facilities
# of Customers:
Municipality/Street & Road
County roads, Commuter Parking
Lots, etc.)
# of Road Miles:
Total:
%
Interstates, Turnpikes & Thruways
# of Road Miles:
Indi
cate the Number & Type of Equipment Used for Snow & Ice Removal Operations:
7.
Plows #
Shovels/Pushers #
Salt Spreaders #
Snow Blowers #
Sweeper Brooms #
Other:
(describe)
Page 3 of 4
8.
Do you require all customers to enter into a written contract?
(If Yes, attach a copy)
If not required 100% of time describe below when contracts are not required:
YES
NO
Do you enter into snow/ice removal contracts written by property owners or other 3
rd
parties? If yes, describe below & provide copies:
YES
NO
Do you provide certificates of insurance to all customers? If not provided 100%,
describe below when not provided:
YES
NO
9.
Do You Have a Log Book? YES NO
If yes, describe information captured in log book or provide sample page:
Snow Removal Workforce - # and Type of Work Performed by the Following:
Principals or Owners:
#
Type of Work:
Payroll: $
Full-Time Employees:
#
Type of Work:
Payroll: $
Part-Time Employees:
#
Type of Work:
Payroll: $
10. Do you use Casual or Day Laborers? ................................................................................................. Yes No
If yes, how many:
11. Are subcontractors ever used for snow removal? ............................................................................. Yes No
Are certificates of insurance obtained from subcontractors? ........................................................... Yes No
Minimum Limits Required: $
Do you use uninsured subcontractors? .................................................................................................. Yes No
If yes, percentage of total subcontracted cost: %
Are written contracts obtained from all subcontractors which include a hold harmless clause in
your favor? ...........................................................................................................................................
Yes No
If no, explain when not required:
Are you named as an additional interest on the subcontractors' policies?...................................... Yes No
Do you normally use the same subcontractors? ............................................................................... Yes No
12. Does Applicant perform any snow plowing in NY?: Yes No If Yes, What Percentage?
Any snow plowing in the 5 Boroughs of NY?: Yes No If Yes, What % of the NY Total?
13. Are you required to name any of your customers as an Additional Insured?: Yes No (If Yes, please attach
a list of customers who require Additional Insured status including whether it needs to be Primary/Noncontributory, include Completed Operations
or if they require a Waiver of Subrogation)
14. Does Applicant Carry Commercial Auto?: Yes No What Limit?
15. A
ny other operations aside from snow removal?
If Yes, are these operations covered elsewhere?: Yes No
16. P
rior Carrier & Premium:
17
. Prior Losses:
Note: 3-5 Year Loss Runs will be Required
Page 4 of 4
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.
APP
LICANT’S NAME AND TITLE:
APPLICANT’S SIGNATURE: ____________________________________________________________________ DATE:
(Must be signed by an active owner, partner or executive officer)
PRODUCER’S SIGNATURE: _______________________________________________________ DATE:
Descriptions and information herein are preliminary to a quote and are not solicitations to buy or offers to sell insurance. Policy issuance
is subject to underwriting approval; refer to any actual policies issued for complete details of coverage, exclusions, and limitations.
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Plowing Program Supplemental Application Snow (Risk Placement Services, Inc.)

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Completed 30 July 2020

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