Business Insurance Application

Contractor BOP Insurance Application

2714 09 08

Tel 262.798.5050
Fax 262.798.5040

Insured Account Number:

This is a: Quote Issue

Billing option: 1-pay 2-pay 4-pay Monthly

[Annual policy term needed for 2-pay, 4-pay, or Monthly]

Deposit amount submitted with application: $

Payment option: Check EFT Credit Card

[Please complete PBS Brochure for EFT or Credit Card]

I. NAMED INSURED

The Named Insured is: Individual Partnership LLC Corp. Other

Mailing Address Tel. No.

City & State Zip Code

Business Location

E-mail Address Website www.

Policy Period: 1 Year From to Coverage is: Bound Unbound

II. GENERAL UNDERWRITING INFORMATION – Please complete these sections for all contractors.

1. Has applicant ever been bankrupt, foreclosed or been refused bonding? Yes Explain. No

2. Individual Social Security Number D.O.B.

Partner Social Security Number D.O.B.

Federal Tax I.D. Number

3. Has any company canceled property, liability, professional or crime insurance for the applicant within the last 5 years? Yes Explain. No

Name of previous Insurer

4. List all claims presented in the last five years. None

5. Other insurance with or applied for to Partners Mutual? Yes Pol. Nos. No

LIABILITY

1. Describe ALL operations

Is the applicant licensed to conduct all operations where required by ordinance or law? Yes* No

2. How long in business? Years experience in the trade

3. Estimated annual payroll $ Estimated annual receipts $

4. How many employees? Full-time: Part-time:

5. Number of jobs done each year Value of largest job $ Average value of all jobs $

6. Does contractor have any other business or anticipate any other liability exposures? Yes Describe.

Shop/Service Office Apartment Mercantile Sq. Ft. Occupied Owner/Occupant Tenant No

7. Does the applicant’s work include any of the following:

Asbestos Waterproofing Boilers

Fire Alarms Work over 2 stories Use of Scaffolding

Tree Trimming Bridge or Dams Sprinkler Systems

EIFS (exterior stucco) Liquid Propane Gas Demolition or Wrecking

Burglar Alarms Use of Cranes Underground

Rivers or Lakes Swimming Pool

8. Does the contractor have a hold harmless or indemnity agreement with anyone? Yes* No

9. Has the contractor ever sold or worked with or on hazardous material, including asbestos, radioactive materials, fumes, acids, wastes or lead? Yes* No

10. Any property of others in contractor’s custody? Value $ Yes* No

11. Does the contractor participate in trade shows, exhibits or conventions? Yes* No

12. Does the contractor sponsor any sporting or social events? Yes* No

13. Does the contractor hire, own or lease watercraft or docks? Yes* No

14. Are storage yards fenced in with good lighting? Yes No*

15. Does the insured contact Digger’s Hotline prior to doing any underground work? Yes No*

16. Is any equipment leased or rented to others? Yes* No

*Explanation Required (see next page)

This is a: Quote ______ Issue ______

Insured Account Number:

Billing option: 1-pay 2-pay 4-pay Monthly

Deposit amount submitted with application: $

Payment option: Check EFT Credit Card

III. SPECIFIC UNDERWRITING INFORMATION

1) Subcontracted work – complete for all contractors

% subcontracted $ total receipts $ receipts subcontracted

Type of work subcontracted:

Are Certificates of Insurance obtained? Yes Limits required $ No

Is applicant named or additional insured by all subcontractors Yes No

2) Snow Plowing

Yes No

Annual Receipts $ Commercial $ Residential $

Any hold harmless agreements? Yes No

Any signed contracts? Yes No

3) Carpentry

What type of work is performed?

Finish Work? Yes No Rough Work? Yes No Cabinet Making? Yes No

Remodeling? Yes No Framing? Yes No Roofing? Yes No

Shop Work? Yes No If shop, is there a dust collection system? Yes No

Any renovation work done? Yes No What %

4) Excavating or Grading of Land

A. Type of work performed:

Sewer/Water Mains Sewer/Water Laterals Gas Lines

Telephone/T.V. Cables Basements/Foundation Walls Septic System

Landfill

What is the maximum depth excavated Are trench boxes used? Yes No

B. Does insured do blasting work? Yes If yes, % No

Or is that work subcontracted out? Yes If yes, % Cost $ No

C. Is any demolition work done Yes Describe above. No

D. Does the insured clear land of trees? Yes No

Does the insured haul logs? Yes No

E. Does the insured haul dirt, sand or gravel for hire? Yes No

F. Are excavations marked and guarded at day’s end? Yes No

G. Are utilities staked prior to any dig? Yes No

Comments

INLAND MARINE

Installation Floater: Total value of equipment installed last 12 months $

Average equipment value at any one site $

Average time required for installation days

Possible maximum loss at any one time at any one location $

Contractor Equipment:

Where is equipment stored when not in use?

Is equipment ever kept at job site overnight?

How protected?

5) Landscaping/Lawn Care Service Contractors

A. Type of work performed:

Landscaping Excavating Grading of Land Landfill

Building of Fences, Walkways, etc. Lawn Care

Tree Trimming and Removal % Tree Height? Blasting? Yes No

Other (describe)

B. Any installation of underground sprinkler systems? Yes No

Any installation of retaining walls? Yes No

C. Are lawn fertilizers/weed control products used? Yes Describe: No

6) Roofing

Please describe the type of roofing work by indicating percentage applicable to:

Residential Commercial Work above 2 stories? Yes No

Asphalt Shingles Metal Hot Tar Wood Rubber

7) Painting

% Inside % Outside

Any spray painting? Yes No Type: Compressed air Airless

Work above 2 stories? Yes No Lead paint remediation? Yes No

Work on bridges, towers or tanks? Yes No

IV.

I understand that as part of Partner’s usual procedure for processing applications and periodic review thereafter, a routine inquiry, including an investigative consumer report, may be initiated by Partners Mutual. If such inquiry is made, further information on the nature and scope of this inquiry is available upon request.

Any person who knowingly and with intent to defraud any insurance company or another 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 and subjects the person to criminal and civil penalties.

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 the company to issue the policy for which I am applying.

CAUTION: READ ALL ITEMS PRIOR TO SIGNING THE APPLICATION

PRODUCERS STATEMENT:

Date:

a. How long have you known applicant? Just Met

c. Direct business: Yes No

b. Transfer within the agency? Yes No

d. Information obtained via: Telephone Personal Interview Mail

Producers Statement: I certify to the best of my knowledge and belief that the signature on this application is the personal signature of the applicant.

PLEASE ANSWER ALL QUESTIONS

V. RATING INFORMATION

Operation #1 Operation #2

Building Occupancy Shop Office Shop Office

Protection Class

Construction Frame Frame Joisted Masonry Joisted Masonry Mas Non-Comb Mas Non-Comb

Operation Description

Liability Class Codes(s)

Premium

Building Limit None $ X Rate per $1,000 =

Contents Limit None $ X Rate per $1,000 =

Liability Operation #1 – Payroll $ X Rate per $1,000 =

Liability Operation #2 – Payroll $ X Rate per $1,000 =

Highest Minimum Liability Premium Applies.

Mortgage Clause Name(s)

Loss Payable Clause Address(es)

Additional Insured (Specify Interest)

VI. OPTIONAL COVERAGES

Additional Insured (Flat Charge Per Location For Each Add’l Interest)

Builders Risk (Only available for owned property which will be occupied by the insured.) Yes Refer to the Commercial Property Program for non-occupied property.

Employee Benefit Administration – Number of employees X =

Employee Dishonesty $5,000 $10,000 $25,000

Inland Marine

Contractors Equipment - 100% Coinsurance Applies – Cranes are not eligible

Actual Cash Value Deduct: $500 $1,000 $2,500 $5000

Unscheduled Property Limit $ X Rate per $1,000 =

Scheduled Property Identification Number Amount of Insurance

Installation Floater - Deductible: $250 $500

Coverage Limit: $5,000 $10,000 $15,000 $20,000 $25,000

Computer Equipment Limit $ X Rate per $1,000 =

Sales and Service Floater Limit $ X Rate per $1,000 =

Money & Securities On Premises $2500 $5000 $7500 $10000 $15000

(Special Form Only) Off Premises $0 $2500 $5000 $7500 $10000

Ordinance or Law – $ debris removal, $ increased construction cost

Partners Plus – Available Only With Special Form Property or IM equipment coverage. $

Sewer Backup – Limit/Premium $5,000/$50 $10,000/$100 $15,000/$150 $20,000/$200

Signs – Limit of Insurance $ X $1.40 per $1,000 =

Tenants Fire Legal Liability ($50,000 Included) $100,000 $250,000 $500,000

Standard Form Building Rate $ X 10 40 90 =

TOTAL PREMIUM

The coverages listed above have been explained to me

I have chosen to insure only the items shown above for which a premium is inserted.

CAUTION: READ ALL ITEMS PRIOR TO SIGNING