Fillable Temporary Employment Agency Application (Kinsale Insurance)

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Temporary Employment Agency Application (Kinsale Insurance)

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The Temporary Employment Agency Application (Kinsale Insurance) form is 5 pages long and contains:

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  • 54 check-boxes
  • 91 other fields

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Page 1 of 5
TEMPORARY EMPLOYMENT AGENCY
ERRORS
& OMISSIONS APPLICATION
1. Legal name of the business who is the primary applicant and will be the first named insured listed on the policy:
2. Please list all other business/dba names for which you are seeking coverage under this policy:
3. Corporation Individual Partnership Municipality For Profit Joint Venture
Other:
4. Please list any names of other entities that you own or manage or that you do business under (such entities are not
requesting coverage under this policy):
5. Primary location address:
6. County of primary location: Date business originally established:
7. Total number of branches? List all addresses for additional branches:
8. What is your web-site address? www.
9. What is your phone number?
10. Has the name or ownership of the entity changed or has any other business been purchased, Yes No
merged or consolidated with the entity within the last 5 years?
11. Does any entity own or control your business or does your business own or control any entity? Yes No
12. During the past five years, has your name been changed or has any other business purchased, Yes No
merged or consolidated with you?
For questions 9-11, please fully explain any “yes” response, including the names, dates, and revenue impact involved:
13. Please list any associations of which you are a member:
1. Full description of services rendered. Coverage will only apply to disclosed premises and operations. Attach all
brochures and promotional materials and contracts:
2. Provide full names of individual and partners:
3. Date your company was established:
4. Receipts for last 12 months: $
Receipts for next 12 months: $
5. Describe qualifications, experience, screening and training of employees:
APPLICANT’S INFORMATION
GENERAL INFORMATION
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 5
6. Do you or are you:
a) Engaged in any other professional activities not listed above? Yes No
b) Have ownership in other entities not listed? Yes No
c) Is your firm engaged in construction, fabrication or production activities? Yes No
d) Do any of your employees hold professional licenses or certifications? Yes No
e) Utilize subcontractors? Yes No
If your answer is YES to any of the above, please attach a separate sheet giving full details and explanation.
7. Please furnish details of your five largest jobs in the last 5 years:
Client Details of Job
1. $
Gross Receipts
2. $
3. $
4. $
5. $
8. Does the applicant utilize a formal written Quality Assurance & Risk Management Program? Yes No
If no, explain.
Is the overall responsibility for Risk Management assigned to one individual in your firm? Yes No
If yes, explain.
If no, how these functions are monitored?
9. Indicate the following number of staff and percentage of receipts from placement:
Description of employees or contracted personnel:
TEMPORARY AGENCIES
Number of
Employees
Number of
Contractors
Receipts for the
Last 12 months
Receipts for the
Next 12 months
Clerical
Professional
Trade
For any professional/trade staff placed, please provide a description of the type of specialty:
THIS SECTION MUST BE COMPLETED
Page 3 of 5
EXECUTIVE SEARCH SERVICES
Last 12 months
Next 12 months
Number of Engagements
Average Salary Level of Placement
Trade
10. Are employees/contractors references contacted before hired/placed? Yes No
How are references checked? Written Verbal Both
If verbal only, please explain:
11. Do you question prospective employees as to any criminal record? Yes No
12. Do you verify certification and/or professional licensure status of employees and Yes No
independent contractors?
13. Are employees screened to rule out drug, alcohol and/or sexual abuse? Yes No
14. Your premium is adjustable based on your total receipts. Our auditor will verify your total receipts.
Provide number of contact person:
( )
15. Has applicant had previous insurance for this enterprise? Yes No
If YES, please complete the following:
Insurance Company
Policy Period to
Limits of Liability
Premium $ Type of Coverage: Occurrence Claims Made
Current General Liability Carrier
Limits requested: $100/$100 $300/$300 $500/$500 $1M/$1M $1M/$2M $1M/$3M
16. During the past five (5) years, have any claims been presented to your current or prior Yes No
insurance carrier or to you?
If YES, please provide full details (Include description of claim, amounts paid, and reserves:
17. Is the applicant, or any other person for whom insurance is being requested, aware of any Yes No
circumstances which may result in a claim?
If YES, please provide full details (Include description of claim, amounts paid, and reserves:
Page 4 of 5
18. Has applicant, or any other person for whom coverage is being requested, had any application Yes No
for liability insurance denied, policy canceled, or non-renewed in the past five (5) years?
If YES, please provide full details (Include description of claim, amounts paid, and reserves:
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.
Page 5 of 5
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.
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)
Applicant’s Signature: _____________________________ Date:
Agent/Broker Name:
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Temporary Employment Agency Application (Kinsale Insurance)

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Completed 15 July 2020

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