Insurance Contractor Application

Insurance Contractor Application

Application Date:

Contractor / Applicant Information

Legal Name of Applicant:

Licenses, Trade and Operations

Policy & Coverage Details Requested

Coverage Types Requested:

Commercial General Liability Professional Liability (E&O) Workers' Compensation

Commercial Auto Builders Risk Umbrella / Excess Liability

Retroactive Date (for claims-made policies, if applicable):

Coverages, Endorsements & Additional Insured

Requested Endorsements:

Additional Insured (per written contract) Waiver of Subrogation Primary & Non-Contributory

Exclusions, Risk Controls and Safety Programs

Describe any known exposures that may be excluded or require special underwriting (e.g., asbestos, pollution liability, excavation below grade):

Claims & Loss History

Have there been any claims, suits, or incidents in the past five years involving the applicant? Yes No

Current pending litigation or unresolved claims? Yes No

Documentation Checklist

Please indicate which documents are attached to this application:

Copy of Contractor License Current Certificate(s) of Insurance

Safety Program / Policies Financial Statements (if requested)

Project References Resumes of Key Personnel

Beneficiary Designation (for policy proceeds where applicable)

Declarations, Authorizations and Fraud Notice

The applicant declares that the statements contained in this application are true and complete to the best of the applicant's knowledge. The applicant understands and agrees that:

1. Material misrepresentation, omission or concealment of fact may be cause for denial of coverage, rescission of the policy, or denial of claims. The applicant will notify the insurer of any material change in the answers or in the nature of operations prior to policy inception or renewal.

2. The insurer is authorized to obtain information from third parties, including but not limited to prior insurers, claims databases, licensing authorities and financial institutions, to verify the information provided and to evaluate underwriting and pricing. The applicant authorizes such inquiries and releases those entities from liability for providing such information.

3. Premiums are subject to audit and adjustment. Failure to report payroll, receipts, contract values or other exposure basis accurately may result in an audit adjustment, additional premium, or cancellation in accordance with the policy terms.

4. In the event of a loss, the insured must give prompt written notice, cooperate with the insurer in the investigation and defense of any claim, and take reasonable steps to prevent further loss.

Insurance Fraud Warning: Any person who knowingly presents false information or conceals material information to obtain insurance coverage or payment may be guilty of insurance fraud and subject to criminal and civil penalties.

By signing below the undersigned certifies that they are authorized to complete and sign this application on behalf of the applicant and that the statements and information contained herein are true and complete.

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