ARTISAN CONTRACTORS GENERAL LIABILITY SUPPLEMENTAL ACCIDENT/MADISON INSURANCE COMPANY
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1 ARTISAN CONTRACTORS GENERAL LIABILITY SUPPLEMENTAL ACCIDENT/MADISON INSURANCE COMPANY APPLICANT INFORMATION: Applicant: Business Address: Contact Name: DBA: Mailing Address: Contact Ph Number: AGENCY INFORMATION: Agency name: Agent s Name: Agency Address: Phone: Fax: NEW VENTURE SUPPLEMENTAL Years under current name: Date business established: If less than 3 years the rest of this section is required Years of related experience: List all business names that applicant/owner has owned in the past: Brief Summary of experience: Page 1 of 5
2 APPLICANT S OPERATIONS 1. Description of applicant s operations (details please): 2. Contractor s license number: 3. Number of owners: Number of employees: 4. What percentage of your work do you subcontract: 5. Direct payroll excluding principals/owners/partners: 6. Insured subcontractor costs: Labor: Materials: 7. Uninsured contractor costs: What type of work will they do for the applicant? 8. Gross receipts last year: Anticipated gross receipts this year: 9. Any waiver of subrogation, AI or per project requirements? Please list number of each: 10. Do you remove or perform any abatement work involving asbestos, fungus, mold or lead? 11. Do your operations involve any outside work over 3 stories or use cranes or booms? 12. Do you sell, install, service or repair alarm systems, fire suppression systems, boilers, escalators, elevators, surveillance or TV monitoring systems or equipment? If yes, please provide details: Page 2 of 5
3 13. Do you manufacture any products? If yes, please provide list of products: 14. Do you do any commercial floorwaxing? If yes, please provide percentage of operations: % If yes, any retail stores, grocery stores or stores open 24hours? 15. Any use of water proofing or pressure washing equipment over 3000 PSI? 16. Any pressure washing of roofs? 17. Do you sell, install, service or repair wood, coal or pellet burning stoves? 18. Are you involved in fiber optic cable work or installation? 19. Are you involved in the sale of chemicals, or the application of chemicals such as herbicides or pesticides? 20. Are you involved in tunneling, dredging, caisson or revetment work? 21. Do you work on student housing, senior housing, assisted living facilities or retirement homes except for repair or remodeling of not more than one unit within a development? 22. Do you do any recreational or playground equipment construction or erection? 23. Do you or any officer, owner or partner have a prior felony conviction? If yes, please provide details and date of conviction: 24. Do your operations include any restoration work involving smoke, fire or water damage? Page 3 of 5
4 25. Do your operations include exterior spray painting? If yes, coverage for overspray is excluded. 26. Do you perform any new construction of condominiums, townhouses, apartments or houses exceeding 25 units in any one tract, project, subdivision or development? If yes, coverage for those operations is excluded. 27. Do you perform or subcontract any demolition or blasting operations? If yes, please provide details: 28. Do your operations include any snow plowing or snow/ice removal? If yes, coverage for those operations are excluded. 29. Do you perform work for or at any petroleum, chemical or other industrial facilities? 30. Have you or the principal been personally bankrupt within the last 5 years? 31. Do your operations include any work on or for airports, elevators, environmental remediation, railroad, swimming pool installation, traffic signals or signage installation, underground tank installation or removal, skylights, exterior insulation finishing systems (E I F S) or synthetic stucco? LOSS HISTORY This business has had general liability claims, totaling $ (paid and reserved) within the past 3 years. There are currently open claims. Have you had any construction defect claims? Page 4 of 5
5 Please explain any yes answers above or enter any comments you have about this risk: Please list any additional insureds: READ AND SIGN BELOW: 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 mis-stated. 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. Applicant s Signature Date Title Producer s Signature Date Page 5 of 5
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THIS IS AN APPLICATION FOR A CLAIMS MADE AND REPORTED POLICY This Application for Architects and Engineers Professional Liability Insurance is intended to be used for the preliminary evaluation of a submission.