Fillable Staffing-Agency-Supplemental ARtisan Contractor Supplemental Application

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Staffing-Agency-Supplemental ARtisan Contractor Supplemental Application

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Page 1 of 5
STAFFING AGENCY SUPPLEMENTAL APPLICATION
COMPLETE IN ADDITION TO ACORD APPLICATIONS.
ATTACH ADDITIONAL SHEETS AS NECESSARY.
ANSWER ALL QUESTIONS. If not applicable, indicate N/A.
1. Named Insured:
2. Mailing Address:
3. Years in business: Years of experience:
4. Website: www.
5. Have you operated or are you operating under a different business name now or at any time Yes No
over the past 10 years? Provide details:
6. If new in business, years of prior experience and type of work performed:
7. Are you licensed? Yes No Type of License? Year issued?
8. Are any of the insured’s operations subbed out? Yes No
a. If yes, what percentage? ____ %
9. State/area of operation:
10. Describe your operations:
11. Have you merged with or acquired any companies in the last 3 years? Yes No
If Yes, provide details and advise how past liabilities were handled in that acquisition. _______________
_____
NAMED INSURED’S INFORMATION
Current Year
1
st
2nd Prior Year
Prior Year
3
rd
4
Prior Year
th
Prior Year
Annual Gross Receipts
Employee Payroll
Cost of Subcontracted Work
# of employees
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 5
Carrier:
Limit of Insurance:
Deductible:
Premium:
Expirations:
12. Please provide a breakdown of the types of positions being staffed by insured:
Type of Work Percentage Type of Work Percentage
Administrative/Clerical % Architects/Engineers %
Computer/IT Services
%
%
Consultant % Crane Operators %
Demolition Services
%
%
Electrical Contractor
%
%
Financial/Accounting Professionals % Industrial Contractors %
Installation/Servicing/Repair % Janitorial Services %
Miners
%
%
Rig Erection/Dismantling % Security Services %
Site prep/Roustabout % Truckers (hauling) %
Truckers (vacuum trucks)
%
%
Other: %
If other, please explain:
13. Does the insured perform criminal background checks on individuals being staffed out? Yes No
14. Does the insured conduct a prior employment check on individuals being staffed out? Yes No
15. Does the insured perform drug tests on individuals being staffed out? Yes No
16. Are employees/contractors’ references contacted before hired/placed? Yes No
17. Will temporary staff be working outside of the Energy industry? Yes No
If yes, please describe:
___________________________________________
18. Does the applicant now, or will the applicant, place their temporary staff in a position which requires
the employee to operate:
a. Cranes, bulldozers, or truckers over 4,000 lbs? Yes No
b. Aircraft of watercraft? Yes No
CURRENT CARRIER INFORMATION
BREAKDOWN OF OPERATIONS
CLIENT SCREENING
Page 3 of 5
19. Will temporary staff be going offshore? Yes No
If yes, what percentage of the time will staff be offshore? _____ %
20. Is there a hold harmless agreement in place between the insured and the temporary employer, in
favor of the insured? Yes No
21. Is the insured providing workers’ compensation for the temporary employees? Yes No
a. If not, is the client providing workers’ compensation for the temporary employees? Yes No
22. During the past five years, has any insurer ever canceled or non—renewed similar insurance to Yes No
any applicant or has your insurance been canceled for non—payment of premium by any insurance
or finance company?
If yes, please explain:
23. Has any lawsuit ever been filed, or any claim otherwise been made against your company or Yes No
any partnership or joint venture of which you have been a member or your company’s predecessors
in business, or against any person, company or entities on whose behalf your company has performed
operations or assumed liability? For the purpose of this application only, a claim means a receipt of
a demand for money, service or arbitration.
If yes, please explain including the name(s) of the person, company or entity and the name(s) and locations(s) of the
projects where such operations were performed. (Attach separate sheet if necessary.)
24. Is your company aware of any occurrences, facts, circumstances, incidents, situations, damages Yes No
or accidents (including but not limited to: allegations of faulty or defective workmanship, product
failure, construction dispute, property damage or construction worker injury) at a location or project
where your company has performed operations that a reasonably prudent person might expect to give
rise to a claim or lawsuit whether valid or not which might directly or indirectly involve the company?
If yes, please explain including the names(s) and location(s) of the projects where such operations were
Performed. (Attach a separate sheet if necessary.)
COVERAGE HISTORY
Page 4 of 5
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.
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.
Page 5 of 5
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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Staffing-Agency-Supplemental ARtisan Contractor Supplemental Application

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Completed 2 July 2020

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