Insurance Contractor Coverage Form

INSURANCE CONTRACTOR COVERAGE FORM

Use this form to apply for contractor insurance coverage or to request changes to existing coverage. Completion of this form constitutes an application and a declaration of facts relied upon for underwriting. Submission does not bind coverage; coverage is effective only upon issuance of a policy, endorsement, or binder by the insurer.

Applicant / Insured Information

Applicant Name:

Individual Corporation LLC Partnership Other:

Contact Person:    Phone:    Email:

Contractor License No.:    State of Issue:    FEIN / SSN:

Business Operations & Financials

Years in Business:    Number of Employees:    Number of Subcontractors:

Policy Details Requested

Policy Type(s) Requested: General Liability Professional Liability Workers' Compensation Commercial Auto Umbrella / Excess Other:

Requested Limits — Per occurrence:    Aggregate:    Deductible / SIR:

Requested Policy Period From:    To:    Estimated Premium:

Coverages & Options

Coverages requested (check all that apply):
Operations Liability Completed Operations Products-Completed Ops Contractual Liability Liability for Independent Contractors
Additional Insured endorsement requested    Waiver of Subrogation requested    Primary & Non-Contributory wording requested

Project / Locations

Claims, Loss History & Attachments

Yes No

Current Certificate of Insurance Loss Runs (last 5 years) Copies of current policies Safety Program / Written Procedures Licenses / Certifications

Beneficiary / Interested Parties (If Applicable)

Designated Beneficiary Name:

Relationship to Applicant:    Percentage (if applicable):

Exclusions, Conditions & Declarations

Exclusions commonly applicable include, but are not limited to, punitive damages where prohibited by law, pollution unless specifically endorsed, professional acts unless Professional Liability is purchased, and intentional acts. Applicant acknowledges that specific policy language governs coverage and that endorsements may impose additional exclusions or limitations.

Certification: I certify that the information provided in this form is true, complete and accurate to the best of my knowledge. I understand that any material misrepresentation or omission may be the basis for denial of coverage or rescission of any policy issued. I authorize the insurer and its agents to obtain loss history, underwriting, and claim information from prior insurers and third-party administrators for underwriting and claims handling purposes.

Binding and Authorization: I understand that submission of this form does not bind the insurer to provide coverage. No coverage is effective until accepted and issued by the insurer. If coverage is bound by broker binder or insurer binder prior to policy issuance, such binder shall be subject to the terms and conditions stated by the binder. I represent that I have authority to complete this application on behalf of the named applicant.

Fraud Notice: Where applicable by law, any person who knowingly presents a false or fraudulent claim, or falsifies information, may be subject to civil or criminal penalties.

Acknowledgement

By signing below, the undersigned declares under penalty of perjury that all statements herein are true and that the undersigned is authorized to make this application. The undersigned further acknowledges receipt of and agreement to the declarations and conditions contained in this form.

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