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

Fill Online, Printable, Fillable, Blank COLONY INSURANCE COMPANY COLONY SPECIALTY INSURANCE COMPANY PELEUS (Strickland Insurance Brokers) Form

Use Fill to complete blank online STRICKLAND INSURANCE BROKERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

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

On average this form takes 18 minutes to complete

The COLONY INSURANCE COMPANY COLONY SPECIALTY INSURANCE COMPANY PELEUS (Strickland Insurance Brokers) form is 4 pages long and contains:

  • 2 signatures
  • 48 check-boxes
  • 43 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Strickland Insurance Brokers forms online.

BROWSE STRICKLAND INSURANCE BROKERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
C‐APP011‐0815 Page1of4
COLONY INSURANCE COMPANY – COLONY SPECIALTY INSURANCE COMPANY
PELEUS INSURANCE COMPANY
CONTRACT DIVISION – DEMOLITION 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:
PROHIBITED (check all that apply to your operations)
Explosives exposures, even if subcontracted out
Hazardous material removal (i.e. asbestos, lead or similar), even if subcontracted out
Leasing cranes to third parties
Pollution remediation, removal
Underground tank removal
Wrecking ball exposures
TYPE OF POLICY
Annual 12 month policy
Short term, job specific policy
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: ___________
Certified Demolition Contractor
C‐APP011‐0815 Page2of4
DEMOLITION CONTRACTORS – SUPPLEMENTAL
CONTRACTS (check if applicable)
Written contracts are always used with third parties. If not, explain:
LOSS HISTORY
Three years of loss history information provided on ACORD application or attached to this application
OPERATIONS / EXPOSURES
States where work is anticipated during the policy term:
Exposure % of
Operations
Exposure % of
Operations
Commercial Demolition Work % Interior (soft) Demolition Work %
Industrial Demolition Work % Exterior (structural) Demolition Work %
Residential Demolition Work %
Total 100 %
Total 100 %
Provide details on additional operations or exposures below if not mentioned above:
Abutting walls may exist with some demolition projects
Demolition by hand
Demolition with equipment:
Bulldozer
Crane – Confirm age, type, size and weight:
_________________________________________________________________________________
Crane – Confirm age, type, size and weight:
_________________________________________________________________________________
Crane – Confirm age, type, size and weight:
_________________________________________________________________________________
Other – Describe: ___________________________________________________________________
Other – Describe: ___________________________________________________________________
Depth of demolition work exceeds 3 feet. If so advise maximum depth in feet: __________________________
Height of demolition may exceed 30 feet. If yes, advise maximum number of feet: _______________________
Employees (total to include leased employees)
Job Cost (average) $
Job Length in Days (average)
Projects - Number anticipated during policy term
Salvage – Annual receipts from salvage sales $
C‐APP011‐0815 Page3of4
DEMOLITION CONTRACTORS – SUPPLEMENTAL
HAZARD CONTROLS
Barricades are always used around the demolition area
Debris is always placed in approved disposal sites owned by third parties
Safety plan exists in writing and is followed
Utility shut-offs are always verified in writing
SUBCONTRACTORS
Use of subcontractors for demolition work is prohibited
EMPLOYEES
Total Number of Employees (include leased employees): __________
PAYROLLS / COSTS
All Owner Payroll (Cap at $16,000 per Owner)
$
All Employee Payroll (if any)
$
All Leased Employee Payroll (if any)
$
RECEIPTS
All Operations
$
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:
COVERAGE OPTIONS - LIABILITY (check if you would like a quote on any of the following)
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
Pollution Exclusion – Limited Exception for Short-Term Event – U680
Professional Extension – Contractors Professional Liability Coverage Limitation – U146
Stop Gap Liability – U066
C‐APP011‐0815 Page4of4
DEMOLITION CONTRACTORS – SUPPLEMENTAL
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
click to sign
signature
click to edit
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

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

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 17 July 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document