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COLONY INSURANCE COMPANY COLONY SPECIALTY INSURANCE COMPANY PELEUS (Strickland Insurance Brokers)

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  • 45 check-boxes
  • 32 other fields

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C‐APP0040‐0815 Page1of3
COLONY INSURANCE COMPANY – COLONY SPECIALTY INSURANCE COMPANY
PELEUS INSURANCE COMPANY
CONTRACT DIVISION - SWIMMING POOL CONTRACTORS - SUPPLEMENTAL APPLICATION
ACORD Application also required - Check all applicable checkboxes below
General Agent:
Date:
Insured:
Insured Mailing Address:
Insured’s Web Address:
Insured Contact Name:
Phone Number:
YEARS IN BUSINESS / EXPERIENCE
_____ Years in business as the ‘Named Insured’ indicated on this application
_____ Years’ experience in the operations indicated on this application - Attach resumes if available
Has applicant had an insurance policy cancelled or non-renewed in past 3 years? If yes, explain.
(Missouri Applicants - Do not answer this question)
Applicant in receivership
Bankruptcy (Chapter 7, 11 or 13) has been filed in past 5 years
LICENSING
Licensed License Number: _________________________________ Year License Issued: _____________
CONTRACTS
Contracts: Written contracts are always used with third parties. If not, explain:
LOSS HISTORY
Three years of loss history information on ACORD application or attached to this application
OPERATIONS
States where work is anticipated during the policy term:
C‐APP0040‐0815 Page2of3
SWIMMING POOL CONTRACTORS - SUPPLEMENTAL APPLICATION
DESIGN / CONSTRUCTION - STANDARDS
Construction always meets Federal swimming pool/spa drain cover standards found in the Virginia Graeme Baker
Pool and Spa Safety Act
EXPOSURES
Cranes used
Yes Crane related work subcontracted
Diving Boards
Commercial Use Residential Use Maximum Height: _____
Pools – Above Ground
Commercial Use Residential Use
Pools – Below Ground
Commercial Use Residential Use
Pools – Spa Type/Hot Tub
Commercial Use Residential Use
Waterslides
Commercial Use Residential Use Maximum Height: _____
DISCONTINUED OPERATIONS / DISCONTINUED NAMED INSUREDS
Acted in the capacity of a General Contractor and/or Construction Project Manager on new-ground-up residential
construction (defined as apartments, condos, co-ops, homes or townhomes) in past 10 years.
Discontinued Operations for this application’s Named Insured(s) in the past 10 years. Provide details below:
Operated under a different ‘Named Insured(s)’ in the past 10 years. Indicate the Named Insured(s) and
corresponding operations for the Named Insured(s) below:
SUBCONTRACTORS
Uninsured subcontractors are not acceptable, except in TX subject to guidelines.
Describe type of work performed by subcontractors:
Risk Transfer – Subcontractors:
A.I.A. Standard s followed when establishing contracts with subcontractors
Additional Insured – Status granted to you on the subcontractor’s policy
Certificates of insurance - Always obtained from a subcontractor prior to any work being done for you.
Hold harmless and Indemnification Agreements – Required from subcontractors
Job to Job - Same set(s) of subcontractors usually used
Limits of Liability - Subcontractors are required to carry limits equal or above your own
Uninsured subcontractors – Sometimes used – Explain:
Workers compensation (if applicable) – Subcontractors required to have their own WC
EMPLOYEES
Number of Employees (include leased employees): __________
Describe type of work performed by employees:
C‐APP0040‐0815 Page3of3
SWIMMING POOL CONTRACTORS - SUPPLEMENTAL APPLICATION
PAYROLLS / COSTS
All Owner Payroll (Cap at $16,000 per Owner)
$
All Employee Payroll (if any)
$
All Leased Employee Payroll (if any)
$
Cost of Insured Subs (if any)
$
Cost of Uninsured Subs (if any)
$
RECEIPTS
All Operations
$
COVERAGE OPTIONS - LIABILITY (check if you would like a quote on any of the following)
Broadened Property Damage for Swimming Pools (Pop-Up) – U502A
Employee Benefit Liability – U058
Employment Practices Liability Insurance – U817 (Not available in AR, LA, MT, NM, NY, VT)
High Limits General Liability
Identity Recovery (i.e. Identity Theft) – U651
Medical Expense Limit of $10,000 rather than $5,000
Professional Extension – Contractors Professional Liability Coverage – (Limited Coverage) – U146
Stop Gap Liability – U066
COVERAGE OPTIONS - PROPERTY (check if you would like a quote on any of the following)
Building Ordinance or Law (Increased Cost of Construction) – U750
Equipment Breakdown – U522 & U523
Property Coverage Enhancement: Bronze – U777C Silver – U777B or Gold – U777A
Signs (Outdoor) – CP1440
Water Back Up and Sump Overflow – U548
GENERAL FRAUD STATEMENT (Not applicable in all states.)
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, may be committing a fraudulent insurance act, and may be subject to
a civil penalty or fine.
The undersigned is an authorized representative of the applicant and certifies that reasonable inquiry has been made to
questions on this application. He/She certifies:
The answers are true, correct and complete to the best of his/her knowledge.
They agree to the Privacy and Fraud provisions found in the ACORD-125 (Commercial Insurance Application) and
understand those provisions also apply to this supplemental application.
SIGN AND DATE
PRODUCER’S SIGNATURE DATE
APPLICANT’S PRINTED NAME DATE
APPLICANT’S SIGNATURE DATE
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COLONY INSURANCE COMPANY COLONY SPECIALTY INSURANCE COMPANY PELEUS (Strickland Insurance Brokers)

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Completed 17 July 2021

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