RON ROTHERT INSURANCE

RON ROTHERT
INSURANCE
SERVICES
Certified Managing General Agent
The Best Service Anywhere
We Want Your Business
ARTISAN CONTRACTORS APPLICATION
ANSWER ALL QUESTIONS-IF THEY DO NOT APPLY, INDICATE "NOT APPLICABLE"
Applicant's Name
Agency Name
Mailing Address
Agent
Address
Web Site Address
E-Mail
Phone
PROPOSED EFFECTIVE DATE: From
Applicant is:
Individual
12:01 A.M., Standard Time at the address of the Applicant
To
Corporation
Partnership
Limited Liability Company
Joint Venture
Other (Specify)
LIMITS OF LIABILITY REQUESTED
TARGET PREMIUMS
General Aggregate
$
Premises/Operations
Products & Completed Operations Aggregate
$
$
Personal & Advertising Injury
$
Products
Each Occurrence
$
$
Damage To Premises Rented To You (any one premise) $
Other
Medical Expense (any one person) $
$
Contractors License Number(s):
Provide state of operations:
Provide details of all your operations:
Do you have other business ventures for which coverage is not requested? ...................................................
Yes
No
Yes
No
If yes, explain and advise where insured:
1. Applicant Operations:
Number of Owner/Partners:
Owner/Partner Payroll:
No. of Trade Employees:
Trade Employee Payroll:
No. of Leased Employees:
Leased Employee Payroll:
What % of work is sub contracted:
Sub Contractor Costs:
If employees are leased, do you use the same employees for every job?
2. Number of Years of Experience:
CON-APP-ART (02-05)
Number of Years in Business:
-1-
3. Indicate percentage of total operations performed by you and/or employees:
Asbestos Removal
% Electrical
%
Masonry
% Roofing Commercial
%
Automatic or Power
Doors
% E.I.F.S.
%
Mechanical
% Roofing Residential
%
Blasting
% Excavation
%
Mining
% Sand Blasting
%
% Seismic Retrofitting
%
Carpentry
% Farm Equipment Repair
%
Mold and Spore Treatment or Remediation
Carpet/Floor Covering
%
Fire and Water Restoration
%
Painting Interior
% Septic
%
Concrete
% Framing (Residential)
%
Painting Exterior
% Sewer
%
Cranes
% Grain Elevators
%
Pile Driving
% Shoring/Underpinning
%
Demolition
% Grading of Land
%
Plastering
% Siding
%
Design
% Home/ Inspections
%
Plumbing Commercial
% Street and Road - Public
%
Drilling
% Insulation
%
Plumbing Residential
% Supervisory Only
%
Drywall
% Landscaping
%
Waterproofing
% Tile & Marble
%
Earthquake Repair
%
Other
%
4. Indicate percentage of total operations performed sub contractors:
Asbestos Removal
% Electrical
%
Masonry
% Roofing Commercial
%
Automatic or Power
Doors
% E.I.F.S.
%
Mechanical
% Roofing Residential
%
Blasting
% Excavation
%
Mining
% Sand Blasting
%
% Seismic Retrofitting
%
Carpentry
% Farm Equipment Repair
%
Mold and Spore Treatment or Remediation
Carpet/Floor Covering
Fire and Water Restora% tion
%
Painting Interior
% Septic
%
Concrete
% Framing (Residential)
%
Painting Exterior
% Sewer
%
Cranes
% Grain Elevators
%
Pile Driving
% Shoring/Underpinning
%
Demolition
% Grading of Land
%
Plastering
% Siding
%
Design
% Home/ Inspections
%
Plumbing Commercial
% Street and Road - Public
%
Drilling
% Insulation
%
Plumbing Residential
% Supervisory Only
%
Tile & Marble
%
Drywall
% Landscaping
Earthquake Repair
%
%
Waterproofing
%
Other
%
Previous Year:
5. Receipts/Sales: Current Year:
Two Years Ago:
6. Indicate % of operations involving:
New Construction:
Repair:
%
%
Remodeling:
Other:
%
%
Demolition:
%
(must total 100%)
Explain other:
Commercial New Construction:
Industrial:
%
%
Commercial Remodeling:
%
Institutional:
%
Residential New:
%
Residential Remodeling:
%
Apartments*:
%
Commercial Condos:
% (must total 100%)
CON-APP-ART (02-05)
-2-
*If residential construction - condos/townhouses (including conversions)
%
single family or residential dwellings
%
*If residential remodeling - interior work only
%
ground up construction
%
7. List three current or planned projects:
Customer Name and Project Description
Cost of Project
Duration of Project
Cost of Project
Duration of Project
a.
b.
c.
8. List five largest jobs in the last 3 years:
Customer Name and Project Description
a.
b.
c.
d.
e.
9. Liability Controls:
a. Do you use a written contract with customers? ....................................................................................
Yes
No
Yes
No
Do your contracts contain a hold harmless agreement in your favor? ................................................. . Yes
No
If no, explain when not required:
b. Do you use a written contract with subcontractors? .............................................................................
If no, explain when not required:
c.
d. Do you obtain certificates of insurance from all subcontractors? .........................................................
Yes
No
e. Are you added as additional insured on the subcontractors' liability policies?.....................................
Yes
No
f.
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
If yes, minimum Limits Required:
Do you have Workers' Compensation coverage in force? ...................................................................
g. Do you provide architectural or engineering design services?.............................................................
If yes, explain:
Do you carry Errors & Omissions coverage for these services? ..........................................................
h. Are you a construction/project manager or consultant? .......................................................................
10. Have you ever had a Construction Defect loss/claim or been involved in a class action Construction Defect suit?................................................................................................................................
If Yes, and loss or suit is older than five years, provide details:
******Please attach separate page reflecting any certificate holders or additional insureds - If
additional insured please advise interest*****
CON-APP-ART (02-05)
-3-
PRIOR CARRIER INFORMATION - FIVE YEAR PERIOD
Year:
Carrier
Policy No.
Total Premium
11. Is the current coverage being cancelled or non-renewed?
Yes
No
LOSS HISTORY-FIVE YEAR PERIOD
Indicate all claims or losses (regardless of fault and whether or not insured) or occurrences that may give rise to claims
for the prior five years.
Date of
Loss
Description of Loss
Amount Paid
Amount
Reserved
Claim Status
(Open or Closed)
***Name & Number of contact for inspection and/or premium audit purposes***:
Name:
Phone #:
This application does not bind the applicant nor the Company to complete the insurance, but it is agreed that the information contained herein shall be the basis of the contract should a policy be issued.
APPLICABLE IN THE STATE OF NEW YORK:
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim 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 shall also be
subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files
an application for insurance or statement of claim 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 such person to criminal and civil penalties.
NAME AND TITLE:
APPLICANT'S SIGNATURE: ______________________________________________
AGENT SIGNATURE:
DATE:
DATE:
IMPORTANT NOTICE
As part of our underwriting procedure, a routine inquiry may be made to obtain applicable information concerning
character, general reputation, personal characteristics and mode of living. Upon written request, additional
information as to the nature and scope of the report, if one is made, will be provided.
ANSWER ALL QUESTIONS-IF THEY DO NOT APPLY, INDICATE NOT APPLICABLE
Print Form
CON-APP-ART (02-05)
-4-