Emergency Responders & Water / Fire Restoration Contractors

Transcription

1 Application Sponsored by Anchor Bay Insurance Managers, Inc. Post Office Box # 2510 / Silverdale, WA Phone: / Fax: Web Site: SurplusLines.com Submit Applications To: Applications@SurplusLines.com Emergency Responders & Water / Fire Restoration Contractors Commercial General Liability (CGL), Contractors Pollution Liability (CPL) and / or Professional Liability (PL) Instructions Please include the following 1. Resumes & licenses of key personal 3. Description of training program with this application: 2. Written safety program 4. Written operating procedures Agency Information Name: Address: City: State: Zip: Phone: Fax: Website: Producer Name: Phone: Assistant Name: Phone: Applicant Information New Business Renewal Business Name: Federal Tax ID#: Legal Name: EPA ID#: Type of Entity: Sole Partnership Joint Venture Corporation LLC Other Mailing Address: City: State: Zip: Physical Address: City: State: Zip: Phone: Fax: Website: Owner or Manager: Phone: Accounting Contact: Phone: Inspection Contact: Phone: Date Applicant was established: For how many years has Applicant performed environmental services? Loss History Currently Valued Loss Runs: Attached Requested Provide prior to binding t available Total claims, lawsuits and/or events or conditions or incidents in the past 5 years that may lead to a future claim or lawsuit: Total paid and reserved for those claims (including defense): $ (Please attach loss runs or a complete description of all) Please provide details of any claims paid or reserved, including defense, that exceed $5,000 1

2 Coverage Information Proposed Effective Date: Proposed Expiration Date: Need by Date: For which of the following coverages is Applicant applying? Commercial General Liability Contractors Pollution Liability Professional Liability Does Applicant require mold coverage? If Yes, attach a mold liability supplement Commercial General Liability Current Coverage is: Occurrence Form Claims Made Form Retroactive Date: / / Deductible / SIR: $ Limits Current Limits Proposed Limits Products & Completed Operations Aggregate General Aggregate Each Occurrence Damage to Rented Premises Medical Payments Employee Benefits Liability If converting from Claims Made to Occurrence, do you wish to include a quote for nose coverage? Defense is currently Included in the policy limit A separate limit of: $ /$ Unlimited, outside the limit Current Coverage includes: CG 2010 Additional Insured CG 2037 Additional Insured I Waiver of Subrogation Primary / Non-Contributory Contractors Pollution Liability Current Coverage is: Occurrence Form Claims Made Form Retroactive Date: / / Deductible / SIR: $ Limits Current Limits Proposed Limits Per Pollution Incident Annual Aggregate If converting from Claims Made to Occurrence, do you wish to include a quote for nose coverage? Defense is currently Included in the policy limit A separate limit of: $ /$ Unlimited, outside the limit Requested Coverage Enhancements: Professional Liability Current Coverage is: Occurrence Form Claims Made Form Retroactive Date: / / Deductible / SIR: $ Limits Current Limits Proposed Limits Per Occurrence, Wrongful Act or Claim Annual Aggregate If converting from Claims Made to Occurrence, do you wish to include a quote for nose coverage? Defense is currently Included in the policy limit A separate limit of: $ /$ Unlimited, outside the limit 2

3 Prior Carrier Information Year Category General Liability Carrier Policy Number Premium Effective Date Expiration Date Retroactive Date Carrier Policy Number Premium Effective Date Expiration Date Retroactive Date Carrier Policy Number Premium Effective Date Expiration Date Retroactive Date Pollution Liability Professional Liability Automobile Excess Liability General Information Has any carrier ever declined, refused to renew or cancelled any insurance that had been issued to Applicant, a predecessor in business, or to a person, firm, organization or joint venture managed by the General Manager, Managing Partner or Joint Venturer or President named above? If Yes, reason: n-payment Agent no longer represents carrier Underwriting Reason (Describe the condition and what has been done to alleviate the problem): Gross Revenue: $ For the upcoming policy year $ For the current policy year $ For the 1st prior policy year $ For the 2nd prior policy year Has Applicant had a foreclosure, repossession, bankruptcy or filed for bankruptcy, judgment or lien during the last five (5) years? If Yes, please provide the following: Occurrence Date Explanation Resolution Resolution Date Do you wish to include Pollution coverage for one or more Fixed Site Pollution exposures, including storage tanks? If Yes, please visit our environmental page for the appropriate storage tank application. 3

4 Operations, Exposures & Controls In which state(s) does the Applicant perform remedial operations? What percentage of Applicant s services are: % Commercial % Residential % Industrial % Other (describe) What percentage of Applicant s services are generated from the following: Client % Revenue Client % Revenue Government - Federal Insurance Companies Government State/Local Insurance Service Providers Homebuilders Plumbers Industrial Other Does Applicant perform inspection or assessment work? If Yes, does Applicant perform the work arising out of the inspection / assessment? What warranties or guarantees do you give regarding the operations and related services you perform? (attach documentation if present) Does Applicant subcontract any operations to others? If Yes, complete the following: Name Address Licensing/Permit Does Applicant perform project supervision work for others? Does Applicant draw plans / design specifications? Have any restoration projects been prematurely terminated? If Yes, describe: Have there been penalties for breach or non-compliance of contract specifications? If Yes, describe: Does Applicant use temporary or casual workers? If Yes, describe how training and qualifications are addressed Does the Applicant have: A formal Training Program A written Safety Program A written Respiratory Protection Program A written Hazard Communication Program (If Yes to any, attach a copy) 4

5 Please complete for all specialties. Professional Services Projected Payroll Projected Subcontract Cost Projected Revenue Air Duct Cleaning Carpet / Upholstery Cleaning Debris Removal Demolition -- Building Demolition -- Interior Emergency Response (Fire Not including reconstruction) Janitorial Mold Inspection & Assessment -- Mold, etc. Mold Post-Remediation Testing & Consulting Mold Remediation Plan Design Reconstruction (Carpentry, Concrete Work, Drywall, Plumbing, Painting, Roofing, HVAC, etc.) Sewage Cleaning Water Extraction / Drying Other (please specify) Total Please complete the following (a complete copy of the GL application schedule may be sufficient): Description of All Other Contracting, Consulting or Other Projected Projected Payroll Operations Subcontract Cost Projected Revenue Recent Jobs (or attach a list) 1 Project Name/Client: 2 Project Name/Client: 3 Project Name/Client: 4 Project Name/Client: 5

6 Recent Jobs (continued) 5 Project Name/Client: 6 Project Name/Client: Additional Insureds Name: Address: City, State, Zip: Insurable Interest:: Lender Landlord Public Entity Other: Loan / Permit #: Name: Address: City, State, Zip: Insurable Interest:: Lender Landlord Public Entity Other: Loan / Permit #: Additional Comments and Explanations Marketing Information Do you control the account now? or do you have any inside edge? If Yes, describe: Price and Terms needed to write the account: Warranty and Signature As a condition precedent to coverage, the undersigned warrants that the information contained herein, including information contained in any and all attachments, is true, complete and free of pertinent omissions and material misrepresentations, and that he/she knows of no claims, lawsuits filed or pending, or events or conditions or incidents which may lead to a future claim or lawsuit. / / Applicant s Signature Applicant s Printed Name Applicant s Title Date 6