Fillable Roofing Supplemental Application (Special Risks)

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Roofing Supplemental Application (Special Risks)

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  • 44 check-boxes
  • 145 other fields

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S369s (05/13) Contains copyrighted material of Insurance Services Office, Inc., with its permission. Page 1 of 6
Roofing Supplemental Application
TO BE USED WITH COMMERCIAL GENERAL LIABILITY APPLICATION (ACORD 125)
All questions must be answered in full. Application must be signed and dated by the applicant.
Applicant’s Name
Agent
Applicant Mailing Address
Applicant’s Phone Number
Web Address
Inspection Contact
Proposed Policy Period to Phone Number for Inspection Contact
Applicant is Individual Partnership Corporation Joint Venture Other
Location #1
Location #2
Location #3
UNDERWRITING
1. Years in Business? Years of Experience in this field?
2. Indicate the percent of each type of roofing performed.
TYPE
COMMERCIAL
RESIDENTIAL
INDUSTRIAL
% OF TOTAL OPERATIONS
N
EW
C
ONSTRUCTION
% % % %
R
EPAIR
/P
ATCHING
% % % %
REPLACEMENT % % % %
F
LAT
R
OOFS
% METAL %
P
ITCH
R
OOFS
% SINGLE PLY %
A
SPHALT
S
HINGLE
%
T
ILE
%
F
IBERGLASS
%
P
OLYURETHANE
F
OAM
%
W
OOD
% HOT TAR %
S
LATE
% TORCH DOWN %
O
THER
-
D
ESCRIBE
3. Describe any other operations or work done other than roofing (e.g., waterproofing, siding, asbestos removal, rain
gutters, carpentry, etc:
4. Describe what safety precautions are in place if hot tar, torch down or other hot processes are used?
Agency Name:
Address:
Contact Name:
Phone:
Fax:
Email:
S369s (05/13) Contains copyrighted material of Insurance Services Office, Inc., with its permission. Page 2 of 6
UNDERWRITING (Continued)
5. What is the maximum height of the buildings you work on?
If over 3 stories, does applicant have a fall protection program in place for all jobs including one of the following systems:
Guardrail system with toes boards ................................................................................................................... Yes No
Saftey net ......................................................................................................................................................... Yes No
Personal fall arrest system .............................................................................................................................. Yes No
6. Do you have a written safety program? .......................................................................................................... Yes No
7. Owner/Partner Payroll $ Subcontractor Cost $
Uninsured Subcontractor Payroll $
Number of Employees $ Employee Payroll $
Leased Employees Payroll $
Total Gross Sales $
8. How do you protect the general public from potential injury?
9. How are materials lifted to the roof?
10. How are openings in the roof protected over night?
11. What precautions do you take when a rainstorm is imminent?
12. Does a foreman or contractor inspect all jobs upon completion? ................................................................... Yes No
13. Have you ever or do you currently perform work in AZ, CA, CO, NV, NY, OR, UT or WA? ............................ Yes No
If yes, please describe.
14. Have you ever used, sold, installed or removed asbestos? ............................................................................ Yes No
If yes explain in detail:
15. Are Cranes used? ............................................................................................................................................ Yes No
If yes, what is the size? Tons: Boom Length:
Are barriers in place to protect the public? ..................................................................................................... Yes No
If yes, are the cranes owned or rented? Owned Rented If rented, attach rental agreement.
If owned, is equipment under a regular maintenance schedule? .................................................................... Yes No
Are employees properly trained and certified? ............................................................................................... Yes No
16. Does the applicant have a “fire watch” program to assure there are no “hot spots” after completion of a
job? .................................................................................................................................................................. Yes No
Describe.
17. Is applicant complying with all state & OSHA regulations? ............................................................................. Yes No
LIMITS – GENERAL LIABILITY (PER OCCURRENCE)
GENERAL AGGREGATE (OTHER THAN PRODUCTS/COMPLETED OPERATIONS) $
PRODUCTS & COMPLETED OPERATIONS AGGREGATE $
PERSONAL & ADVERTISING INJURY (ANY ONE PERSON OR ORGANIZATION) $
EACH OCCURRENCE $
DAMAGE TO PREMISES RENTED TO YOU (ANY ONE PREMISES) $
MEDICAL EXPENSE (ANY ONE PERSON) $
S369s (05/13) Contains copyrighted material of Insurance Services Office, Inc., with its permission. Page 3 of 6
ROOFING CONTRACTORS
1. Does applicant draw plans, designs or specifications? ................................................................................... Yes No
If yes, describe.
2. Do your subcontractors carry coverage or limits less than yours? ................................................................. Yes No
If yes, what are the minimum limits you accept?
3. Are certificates of insurance required from subcontractors? ........................................................................... Yes No
Do the subcontractors list the applicant as an Additional Insured? ................................................................ Yes No
4. Is a signed subcontract agreement used with all subcontractors? ................................................................. Yes No
If yes, attach a copy for our file. If no, risk may not be acceptable.
5. How long are Certificates of Insurance kept? ...................................................... Until job ends One year Other
If other is checked, provide details.
6. Describe the type of work subcontracted indicating percent for each category:
7. Does applicant lease equipment to others with or without operators? ............................................................ Yes No
If yes, describe equipment and forward copy of lease agreement:
8. What is the number of employees? .............................................................................. Full-time Part-time
9. List Gross Sales for the last three years:
Year 20 Gross Sales $
Year 20 Gross Sales $
Year 20 Gross Sales $
10. Do you offer warranties? ................................................................................................................................. Yes No
If yes, attach copies of warranty.
CONTRACTUAL LIABILITY
Describe All Hold Harmless Agreements (Dates, Contracting Party, Cost) and attach copies.
CERTIFICATE RECIPIENTS / ADDITIONAL INTERESTS
N
AME AND ADDRESS
R
ELATIONSHIP
TO APPLICANT
A
DDITIONAL
INSURED
CERTIFICATE
S369s (05/13) Contains copyrighted material of Insurance Services Office, Inc., with its permission. Page 4 of 6
LIST THREE (5) OF YOUR LARGEST JOBS AND TYPE OF PROCESS USED IN THE LAST FIVE (5) YEARS
JOBS TYPE OF PROCESS USED
ADDITIONAL INFORMATION OR COMMENTS
PLEASE READ BELOW AND COMPLETE SIGNATURE BLOCK ON LAST PAGE
I have reviewed this application for accuracy before signing it. As a condition precedent to coverage, I hereby state that the
information contained herein is true, accurate and complete and that no material facts have been omitted, misrepresented or
misstated. I know of no other claims or lawsuits against the applicant and I know of no other events, incidents or occurrences
which might reasonably lead to a claim or lawsuit against the applicant. I understand that this is an application for insurance
only and that completion and submission of this application does not bind coverage with any insurer.
IMPORTANT NOTICE: As part of our underwriting procedure, a routine inquiry may be made to obtain applicable information
concerning character, general reputation, personal characteristics, and mode of living. Upon written request, additional
information as to the nature and scope of the report, if one is made, will be provided.
FRAUD STATEMENT – FOR THE STATE(S) OF:
Alabama, Arkansas, Connecticut, Delaware, District of Columbia, Georgia, Idaho, Illinois, Indiana, Iowa, Kentucky,
Louisiana, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New
Hampshire, North Carolina, North Dakota, Rhode Island, South Carolina, South Dakota, Texas, Utah, Vermont, West
Virginia, Wisconsin, Wyoming:
NOTICE: In some states, any person who knowingly (For Maryland add: or willfully) presents a false or fraudulent claim for
payment of a loss or benefit or knowingly (For Maryland add: or willfully) presents false information in an application for
insurance is guilty of a crime and may be subject to (For Alabama add: restitution,) fines and confinement in prison (For
Alabama add: or any combination thereof).
Maine, Tennessee, Virginia, 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.
Alaska
A person who knowingly and with intent to injure, defraud, or deceive an insurance company files claim containing false,
incomplete, or misleading information may be prosecuted under state law.
Arizona
For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a
false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.
California
For your protection, California law requires that you be made aware of the following: Any person who knowingly presents false
or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
S369s (05/13) Contains copyrighted material of Insurance Services Office, Inc., with its permission. Page 5 of 6
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.
Florida
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 of the third degree.
District of Columbia
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.
Hawaii
Intentionally or knowingly misrepresenting or concealing a material fact, opinion or intention to obtain coverage, benefits,
recovery or compensation when presenting an application for the issuance or renewal of an insurance policy or when
presenting a claim for the payment of a loss is a criminal offense punishable by fines or imprisonment, or both.
Idaho
Any person who knowingly, and with intent to defraud or deceive any insurance company, files a statement of claim
containing any false, incomplete, or misleading information is guilty of a felony.
Indiana
Any person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete, or
misleading information commits a felony.
Kansas
Any person who commits a fraudulent insurance act is guilty of a crime and may be subject to restitution, fines and
confinement in prison. A fraudulent insurance act means 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 or insurance agent or broker, any written statement as part of, or in support of, an application for insurance,
or the rating of an insurance policy, or a claim for payment or other benefit under an insurance policy, which such person
knows to contain materially false information concerning any material fact thereto; or conceals, for the purpose of misleading,
information concerning any fact material thereto.
Minnesota
Any person who files a claim with intent to defraud or help commit a fraud against an insurer is guilty of a crime.
New Hampshire
Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing
any false, incomplete, or misleading information is subject to prosecution and punishment for insurance fraud, as provided in
RSA 638:20.
New Jersey
Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal
and civil penalties.
New Mexico
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.
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 also be
subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
Ohio
Any person who, with intent to defraud or knowing that he 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.
Oklahoma
WARNING – Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the
proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
S369s (05/13) Contains copyrighted material of Insurance Services Office, Inc., with its permission. Page 6 of 6
Oregon
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents
materially false information in an application for insurance may be guilty of a crime and may be subject to fines and
confinement in prison. In order for us to deny a claim on the basis of misstatements, misrepresentations, omissions or
concealments on your part, we must show that:
A. The misinformation is material to the content of the policy;
B. We relied upon the misinformation; and
C. The information was either:
1. Material to the risk assumed by us; or
2. Provided fraudulently.
For remedies other than the denial of a claim, misstatements, misrepresentations, omissions or concealments on your part
must either be fraudulent or material to our interests. With regard to fire insurance, in order to trigger the right to remedy,
material misrepresentations must be willful or intentional. Misstatements, misrepresentations, omissions or concealments on
your part are not fraudulent unless they are made with the intent to knowingly defraud.
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.
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Roofing Supplemental Application (Special Risks)

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Completed 9 July 2021

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