Fillable Swimming Pool Contractors, Dealers and Installers Supplemental Application (RT Specialty)

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Swimming Pool Contractors, Dealers and Installers Supplemental Application (RT Specialty)

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The Swimming Pool Contractors, Dealers and Installers Supplemental Application (RT Specialty) form is 4 pages long and contains:

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  • 8 check-boxes
  • 104 other fields

Country of origin: US
File type: PDF

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Scottsdale Insurance Company
Home Office: One Nationwide Plaza
Columbus, Ohio 43215
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
Scottsdale Indemnity Company
Home Office: One Nationwide Plaza
Columbus, Ohio 43215
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
Scottsdale Surplus Lines Insurance Company
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
1-800-423-7675 • Fax (480) 483-6752
www.scottsdaleins.com
Swimming Pool Contractors, Dealers and Installers Supplemental Application
(Complete in addition to ACORD General Liability Application)
Name of Applicant:
Web site Address:
Location Address:
Employee Data
Number
Annual Payroll
Owner(s) only
$
Retail: Full Time
$
Part Time
$
Installation: Full Time
$
Part Time
$
Leased or Subcontracted Number Annual Cost
Leased Employees
$
Independent Contractors
$
Receipts
In-ground installation
$
Above-ground installation
$
Retail
$
1. Limited Coverage for Property Damage from Swimming Pool Pop Up limits:
$50,000 per occurrence/$100,000 aggregate (included) Other Limits: Exclude
2. Does applicant or subcontractors use explosives? .............................................................................. Yes No
If yes, complete and submit the Blasting Contractors Supplemental Application, GLS-APP-67s.
3. Does applicant make a thorough study of the subsurface, including identification of existing
utility pipes and lines, prior to any digging? ..........................................................................................
Yes No
4. If shoring is required on a job, does applicant use OSHA-approved equipment and techniques? .. Yes No
GLS-APP-14s (4-11) Page 1 of 4
Submit Application
5. Does applicant have sufficient signs, barricades and fences to keep non-employees at a safe
distance from job sites and equipment? .................................................................................................
Yes No
Equipment is: owned; or rented
If rented, attach a copy of the certificate of insurance from the rental company.
6. Does applicant rent portable spas? ......................................................................................................... Yes No
7. Does applicant manufacture or sell any products under their own label? .......................................... Yes No
If yes, complete and submit the Products Liability Application.
8. Any underground tanks, petroleum products, LPG, flammable liquids or explosives stored on
premises? ...................................................................................................................................................
Yes No
If yes, type and quantity stored:
9. Any equipment loaned, leased or rented to others? .............................................................................. Yes No
If yes, describe type of equipment and annual rental receipts:
10. Does applicant provide lifeguard services? ........................................................................................... Yes No
11. Does applicant perform pool servicing, repair, cleaning or chemical maintenance? ........................ Yes No
12. Does applicant subcontract work? .......................................................................................................... Yes No
If yes, describe type of work:
13. Are certificates of insurance obtained from subcontractors? .............................................................. Yes No
Minimum limits required of subcontractors:
14. Does applicant install diving boards, slides or other accessories? .................................................... Yes No
If yes, indicate estimated number of diving boards or slides installed annually for each of the following:
Diving Boards Slides
under 10 feet in height
over 10 feet in height
Describe other accessories installed:
Does applicant install water slides for commercial clients? ......................................................................... Yes No
15. Are all operations in compliance with the federal Virginia Graeme Baker Pool and Spa Safety
Act? .............................................................................................................................................................
Yes No
16. Does applicant comply with the National Spa & Pool Institute’s (NSPI) minimum standards of
pool installation? .......................................................................................................................................
Yes No
17. Does applicant sell products other than pool supplies? ....................................................................... Yes No
If yes, nature of items sold:
18. Are all chemicals EPA-approved and stored in EPA-approved containers? ....................................... Yes No
19. Does risk engage in the generation of power, other than emergency back-up power, for their
own use or sale to power companies? ....................................................................................................
Yes No
If yes, describe:
20. Does applicant have other business ventures for which coverage is not requested? ...................... Yes No
If yes, explain and advise where insured:
GLS-APP-14s (4-11) Page 2 of 4
This application does not bind the applicant nor the Company to complete the insurance, but it is agreed that the infor-
mation contained herein shall be the basis of the contract should a policy be issued.
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 sub-
jects such person to criminal and civil penalties. Not applicable in Nebraska, Oregon and Vermont.
NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or in-
formation 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 policy holder 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.
WARNING TO DISTRICT OF COLUMBIA APPLICANTS: 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 addi-
tion, 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 insurer
files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony
in the third degree.
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 sub-
ject to fines and confinement in prison.
NOTICE TO OHIO APPLICANTS: Any person who knowingly and with intent to defraud any insurance company 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 sub-
jects such person to criminal and civil penalties.
NOTICE TO OKLAHOMA APPLICANTS: Any person who knowingly, and with intent to injure, defraud or deceive any in-
surer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information
is guilty of a felony.
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 a denial of
insurance benefits.
NOTICE TO MARYLAND APPLICANTS: Any person who knowingly and willfully presents a false or fraudulent claim for
payment of a loss or benefit or who knowingly and willfully 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 RHODE ISLAND 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.
FRAUD WARNING (Applicable in Tennessee, Virginia and Washington): It is a crime to knowingly provide false, in-
complete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include
imprisonment, fines and denial of insurance benefits.
GLS-APP-14s (4-11) Page 3 of 4
NOTICE TO NEW YORK APPLICANTS (Other than automobile): 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.
APPLICANT’S NAME AND TITLE:
APPLICANT’S SIGNATURE: _______________________________________________________ DATE:
(Must be signed by an active owner, partner or executive officer)
PRODUCER’S SIGNATURE: _______________________________________________________ DATE:
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
.
GLS-APP-14s (4-11) Page 4 of 4
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Swimming Pool Contractors, Dealers and Installers Supplemental Application (RT Specialty)

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Completed 13 December 2020

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