Fill - Free fillable TELECOMMUNICATION TOWERS SUPPLEMENTAL APPLICATION (Colonial General Insurance Agency, Inc) PDF form

GLS-SUPP-3g (7-17) Page 1 of 6

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

TELECOMMUNICATION TOWERS SUPPLEMENTAL APPLICATION

(Complete in addition to the ACORD General Liability Application)

Applicant’s Name:

Location Address:

Agent Name:

Agent Address:

Phone No.:

PROPOSED EFFECTIVE DATE: From To 12:01 A.M., Standard Time at the address of the Applicant

PLEASE ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE” (N/A)

1. Applicant Operations:

Description of Operations:

b. State/Area of Operations:

c. Length of time in business operating under the name shown above: years or new ven-

ture

d. Gross receipts annually: ........................................................................................................................ $

e. Total payroll: .......................................................................................................................................... $

• Tower Service or Repair:

Payroll $ Subcontractor Costs $ Sales $

• Tower Erection:

Payroll $ Subcontractor Costs $ Sales $

• Tower Modification:

Payroll $ Subcontractor Costs $ Sales $

• Telephone or Cable Television Line Construction:

Payroll $ Subcontractor Costs $ Sales $

• Uninsured Subcontractors Cost: $

f. Is applicant licensed? ............................................................................................................................ Yes No

If yes, type in license and number:

Year licensed issued: ............................................................................................................................

Has applicant operated or been licensed under any other name(s) during the past ten (10) years? Yes No

If yes, provide prior name and describe type of operations:

GLS-SUPP-3g (7-17) Page 2 of 6

g. List top three customers and services performed:

Customer Services Performed

h. Projects:

Current or Planned Projects Cost of Project Duration of Project

2. Liability Controls:

a. Does applicant use a written contract with customers? ........................................................................ Yes No

If no, explain when not required:

b. Total cost of subcontracted work, including cost of materials: ............................................................. $

c. Does applicant use a written contract with subcontractors? ................................................................. Yes No

If no, explain when not required:

d. Advise percentage of work subcontracted: ........................................................................................... %

e. Do applicant’s contracts contain a hold harmless agreement in applicant’s favor? ............................. Yes No

f. Does applicant obtain certificates of insurance from all subcontractors? ............................................. Yes No

If yes, minimum limits required: ............................................................................................................ $

g. Is applicant added as an additional insured on the subcontractors’ liability policies? .......................... Yes No

h. Does applicant have Workers’ Compensation coverage in force? ....................................................... Yes No

i. Does applicant provide architectural or engineering design services? ................................................. Yes No

If yes, explain:

j. Is applicant involved in television or radio receiving set installation or repair? ..................................... Yes No

k. Is applicant a cable or subscription television company? ..................................................................... Yes No

l. Is applicant a telecommunication equipment provider? ........................................................................ Yes No

m. Is applicant a telecommunication service provider? ............................................................................. Yes No

n. Has applicant acted in the capacity of a General Contractor in the past? ............................................ Yes No

If yes, provide details:

o. Is applicant a construction/project manager or consultant? .................................................................. Yes No

p. Has applicant been involved in any claims involving construction defects? ......................................... Yes No

If yes, explain:

3. Does applicant or subcontractors do directional drilling? ................................................................... Yes No

4. Does applicant or subcontractors use explosives? .............................................................................. Yes No

5. What is the average height of towers serviced?

GLS-SUPP-3g (7-17) Page 3 of 6

6. What is the maximum height of towers serviced?

7. Any work on towers located on buildings? ............................................................................................ Yes No

If yes, explain:

8. Does applicant or subcontractor do any tower inspections? .............................................................. Yes No

9. Does applicant or subcontractor do any tower modifications (ie, reinforcing/modifying the

structure and/or load bearing capabilities of the tower)? .....................................................................

Yes No

If yes, explain:

10. Does applicant or subcontractor do any tower erection? .................................................................... Yes No

If yes:

Average height of towers:

Maximum height of towers erected:

Number of towers erected on buildings:

Number of towers erected per year:

11. Does applicant have written safety procedures for all employees and subcontractors? ................. Yes No

Do employees use safety harnesses?......................................................................................................... Yes No

Are underground utilities marked? ............................................................................................................... Yes No

Is safety program reviewed quarterly with employees? .............................................................................. Yes No

If no, how often is it reviewed?

12. Does applicant do any excavation work? ............................................................................................... Yes No

If yes, complete the Excavators and Grading of Land Supplemental Application.

13. Does applicant do any welding work? .................................................................................................... Yes No

If yes, advise percentage of gross receipts: ................................................................................................ %

14. For tower owners:

Number of towers owned: ............................................................................................................................

Height of each tower: ................................................................................................................................... Feet

Are towers located on buildings? ................................................................................................................. Yes No

Are towers used by anyone else? ............................................................................................................... Yes No

What are the annual receipts from leasing space on towers to others? ..................................................... $

Does weight of any attached antennas exceed the maximum weight recommended by the

manufacturer? ..............................................................................................................................................

Yes No

Are towers grounded and equipped with lightning arresters? ..................................................................... Yes No

Are towers supported by wires? .................................................................................................................. Yes No

Advise wind load of each tower:

Tower Security:

Fully fenced? ......................................................................................................................................... Yes No

Cameras? .............................................................................................................................................. Yes No

15. 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:

GLS-SUPP-3g (7-17) Page 4 of 6

16. Does applicant have other business ventures for which coverage is not requested? ...................... Yes No

If yes, explain and advise where insured:

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

subjects such person to criminal and civil penalties. (Not applicable in AL, CO, DC, FL, KS, LA, ME, MD, MN, NE, NY,

OH, OK, OR, RI, TN, VA, VT or WA.)

NOTICE TO ALABAMA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a

loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be

subject to restitution fines or confinement in prison, or any combination thereof.

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 pay-

able 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 appli-

cant.

NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any insur-

er files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a fel-

ony of the third degree.

NOTICE TO KANSAS APPLICANTS: Any person who, knowingly and with intent to defraud, presents, causes to be pre-

sented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any

agent thereof, any written, electronic, electronic impulse, facsimile, magnetic, oral, or telephonic communication or state-

ment as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or

commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal

insurance which such person knows to contain materially false information concerning any fact material thereto; or con-

ceals, 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.

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 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 or willfully presents a false or fraudulent claim for

payment of a loss or benefit or who knowingly or 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 MINNESOTA APPLICANTS: A person who files a claim with intent to defraud or helps commit a fraud

against an insurer is guilty of a crime.

GLS-SUPP-3g (7-17) Page 5 of 6

NOTICE TO OHIO APPLICANTS: 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.

GLS-SUPP-3g (7-17) Page 6 of 6

NOTICE TO OKLAHOMA APPLICANTS: 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 infor-

mation is guilty of a felony.

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 VERMONT, NEBRASKA AND OREGON): Any person who intentionally presents

a materially false statement in an application for insurance may be guilty of a criminal offense and subject to penalties un-

der state law.

FRAUD WARNING (APPLICABLE IN TENNESSEE, VIRGINIA AND WASHINGTON): It is a crime to knowingly provide

false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penal-

ties include imprisonment, fines, and denial of insurance benefits.

NEW YORK OTHER THAN AUTOMOBILE 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 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 STATEMENT:

I have read the above application and I declare that to the best of my knowledge and belief all of the foregoing statements

are true, and that these statements are offered as an inducement to us to issue the policy for which I am applying. (Kan-

sas: This does not constitute a warranty.)

APPLICANT’S SIGNATURE: DATE:

CO-APPLICANT’S SIGNATURE: DATE:

PRODUCER’S SIGNATURE: DATE:

AGENT NAME: AGENT LICENSE NUMBER:

(Applicable to Florida Agents Only)

IOWA LICENSED AGENT:

(Applicable in Iowa Only)

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.

click to sign

signature

click to edit

click to sign

signature

click to edit

click to sign

signature

click to edit

Download
Save PDF to desktop

Email
Email completed PDF

Send for Signing
Email for others to sign

Print
Print document

NAME

TELECOMMUNICATION TOWERS SUPPLEMENTAL APPLICATION (Colonial General Insurance Agency, Inc)

View Audit Log
Print With Audit Log
Duplicate Document

Fill Online, Printable, Fillable, Blank TELECOMMUNICATION TOWERS SUPPLEMENTAL APPLICATION (Colonial General Insurance Agency, Inc) Form

Related forms

Fillable TELECOMMUNICATION TOWERS SUPPLEMENTAL APPLICATION (Colonial General Insurance Agency, Inc)

Fill Online, Printable, Fillable, Blank TELECOMMUNICATION TOWERS SUPPLEMENTAL APPLICATION (Colonial General Insurance Agency, Inc) Form

Related forms

First 20 documents completely FREE!