COMMERCIAL GENERAL LIABILITY ADDITIONAL INFORMATION
Your Agency: Insurance Assurance, Inc.
The insured needs an occurrence-based commercial general liability policy.
The insured is willing to pay up to a $2,500 deductible for each occurrence of property damage or bodily injury.
Limits must be on a per-project basis with the following limit amounts,
• General Aggregate = $2,000,000
• Products & Completed Operations Aggregate = $2,000,000
• Personal & Advertising Injury = $1,000,000
• Each Occurrence = $1,000,000
• Damage to Rented Premises = $100,000
• Medical Expense = $5,000
• Employee Benefits = $1,000,000
The insured has a total of 11 employees and all are covered by employee benefits plans. The employee benefits plan started 5/11/2015 and they are willing to pay up to a $2,500 deductible per employee benefits liability claim.
The insured needs additional forms & endorsements attached via ACORD 829. They are as follows,
FORM NUMBER FORM NAME
CG 20 33 04 13 Additional Insured: Automatic Status When Required in Construction CG 20 37 04 13 Additional Insured: Completed Operations
CG 20 01 04 13 Primary and Noncontributory: Other Insurance Condition CG 24 04 04 13 Waiver of Transfer of Rights of Recovery Against Others To You
SUPPLEMENTAL APPLICATION
Hot Conditioned Air, Inc.
1. General Liability Exposure. Please note any changes/corrections:
Class Code Classification Description Premium Basis 2017 Estimates
95647 Heating or Combined Heating and Air Conditioning Systems or Equipment: Dealers or Distributors and Installation, Servicing or Repair
Gross Sales $1,750,000
95647 Heating or Combined Heating and Air Conditioning Systems or Equipment: Dealers or Distributors and Installation, Servicing or Repair
Payroll $563,000
91585 Contractors; Subcontracted Work; In Connection with Construction, Reconstruction, Repair or Erection of Buildings
Total Cost $70,000
2. Are you a contractor? ☒ Yes
☐ No (If no, skip to “3”)a. Do you draw plans, designs, or specifications for others? ☐ Yes☒ No i. If yes, please explain:
b. Do your operations include blasting or utilizing/storing explosive material? ☐ Yes
☒ Noi. If yes, please explain:
c. Do your operations include excavation, tunneling, underground work or earth moving? ☐ Yes
☒ Noi. If yes, please explain:
d. Do your subcontractors carry coverages or limits less than yours? ☐ Yes☒ No i. If yes, please explain:
e. Are subcontractors allowed to work without providing you with a certificate of insurance? ☐ Yes☒ No i. If yes, please explain:
f. Do you lease equipment to others with or without operators? ☐ Yes☒ No i. If yes, please explain:
g. Describe the type of work you subcontract: Cranes 3. How much do you annually pay subcontractors? $70,000 4. What percentage of work is subcontracted? 4 %
5. What number of staff to you employ? Full-time 10 Part-time 1
6. List the products sold or services offered and your annual gross sales for each.
Products Annual Gross Sales
HVAC Work $1,750,000
7. Do you install, service or demonstrate products?
☒ Yes☐ Noi. If yes, please explain: Service ventilation systems.
8. Do you sell, distribute, or use as components foreign products?
☐ Yes☒ Noi. If yes, please explain:
9. Do you conduct any R&D or have any new products planned for next year?
☐ Yes☒ Noi. If yes, please explain:
10. Do you have any product guarantees, warranties, or hold harmless agreements?
☐ Yes☒ Noi. If yes, please explain:
11. Are your products related to the aircraft/space industry?
☐ Yes☒ Noi. If yes, please explain:
12. Do you have any recalled, discontinued, changed products?
☐ Yes☒ Noi. If yes, please explain:
13. Do you sell or re-packaged other’s products under your label?☐ Yes☒ No
i. If yes, please explain:
SUPPLEMENTAL APPLICATION (continued)
14. Do you have any products under the label of others? ☐ Yes☒ No
i. If yes, please explain:
15. Is coverage required for any vendors? ☐ Yes ☒ No
i. If yes, please explain:
16. Will persons covered by the insurance policy sell products/services to others under the same policy? ☐ Yes ☒ No
i. If yes, please explain:
17. Do you provide medical facilities or employ/contract any medical professionals? ☐ Yes ☒ No
i. If yes, please explain:
18. Do you have operations exposed to radioactive/nuclear material? ☐ Yes☒ No
i. If yes, please explain:
19. Have you ever stored, treated, discharged, applied, disposed or transported hazardous material? ☐ Yes☒ No
i. If yes, please explain:
20. Have you had any operations sold, acquired, or discontinued within the last five years? ☐ Yes☒ No
i. If yes, please explain:
21. Do you rent or loan equipment to others? ☐ Yes ☒ No
i. If yes, please explain:
22. Do you own/hire/lease any watercraft, docks, or floats? ☐ Yes☒ No
i. If yes, please explain:
23. Do you own/rent any parking facilities? ☐ Yes☒ No
i. If yes, please explain:
24. Do you charge a fee for parking? ☐ Yes☒ No
i. If yes, please explain:
25. Do you provide any recreational facilities? ☐ Yes ☒ No
i. If yes, please explain:
26. Do you have any lodging operations? ☐ Yes ☒ No
i. If yes, please explain:
27. Do you have a swimming pool on the premises? ☐ Yes ☒ No
i. If yes, please explain:
28. Do you sponsor any social events? ☐ Yes☒ No
i. If yes, please explain:
29. Do you sponsor any athletic teams? ☐ Yes☒ No
i. If yes, please explain:
30. Have you thought about making any structural alterations to any of your locations? ☐ Yes ☒ No
i. If yes, please explain:
31. Have you thought about demolishing any structures at any of your locations? ☐ Yes ☒ No
i. If yes, please explain:
32. Have you ever been active in a joint venture? ☐ Yes☒ No
i. If yes, please explain:
33. Do you lease employees to or from other employers? ☐ Yes☒ No
i. If yes, please explain:
34. Do you interchange labor with any other business or subsidiary? ☐ Yes☒ No
i. If yes, please explain:
35. Do you operate/control any day care facilities? ☐ Yes ☒ No
i. If yes, please explain:
36. Have any crimes occurred or been attempted on your premises within the last three years? ☐ Yes ☒ No
i. If yes, please explain:
37. Do you have a formal, written safety and security policy in effect? ☒ Yes☐ No i. If yes, please explain: Written HVAC safety policy book.
38. Does your promotional literature make representations about the safety of your premises? ☐ Yes☒ No
i. If yes, please explain:
LOSS RUN BY POLICY
Policy Number:
Name of Insured:
Name of Agent:
Carrier Name:
ABCD98569856 Hot Conditioned Air, Inc.
Insurance Assurance, Inc.
THE ULTIMATE INSURANCE COMPANY
Policy Period: 05/11/2016 TO 05/11/2017
160554587 05/11/2016 CA
Open
Claimants allege insured installed a AC unit improperly that caused the unit to pull air from holes in the wall cavity that had continuity with an unventilated and closed parking garage and chemical storage closet directly below the plaintiff's unit ,which caused health problems .
Old Claim#:
Loss Paid Med Paid Exp Paid Current
Loss Resv
Current Exp Resv
Current Med Resv
Gross Incurred
Expense Recovery
Deduct Recovery
Salvage Recovery
Subro Recovery
Date Closed: Claim Status:
Date of Loss: Accident State:
09/02/2017 Line/Cov
Driver:
Unit Number:
St Claim #:
Date Open:
Description of Accident:
Claimant Ronald McDonalds & Hamburglar
17.2/GLCO O $0.00 $0.00 $0.00 $0.00 $2,500.00 $0.00 $2,500.00 $0.00 $0.00 $0.00 $0.00
Group Total for Claim No: 160554587 $0.00 $0.00 $0.00 $0.00 $2,500.00 $0.00 $2,500.00 $0.00 $0.00 $0.00 $0.00
NUMBER OF CLAIMS IN PERIOD: 1
TOTALS IN PERIOD: $0.00 $0.00 $0.00 $0.00 $2,500.00 $0.00 $2,500.00 $0.00 $0.00 $0.00 $0.00
Loss Paid Med Paid Exp Paid Current
Loss Resv
Current Exp Resv
Current Med Resv
Gross Incurred
Expense Recovery
Deduct Recovery
Salvage Recovery
Subro Recovery SUB TOTALS for Policy Period: 05/11/2016 TO 05/11/2017
Page 1 of 2
Created by: Claims Activity as of 01/26/2018 Run Date: 1/27/2018 11:24:54AM
LOSS RUN BY POLICY
Policy Number:
Name of Insured:
Name of Agent:
Carrier Name:
Policy Period: 05/11/2017 TO 05/11/2018
15648757 05/11/2017 CA
Open
Claimants allege insured installed a AC unit improperly that caused the unit to pull air from holes in the wall cavity that had continuity with an unventilated and closed parking garage and chemical storage closet directly below the palintiff's unit ,which caused health problems.
Old Claim#:
Loss Paid Med Paid Exp Paid Current
Loss Resv
Current Exp Resv
Current Med Resv
Gross Incurred
Expense Recovery
Deduct Recovery
Salvage Recovery
Subro Recovery
Date Closed: Claim Status:
Date of Loss: Accident State:
09/07/2017 Line/Cov
Driver:
Unit Number:
St Claim #:
Date Open:
Description of Accident:
Claimant Ronald McDonalds & Hamburglar
17.2/GL O $0.00 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $0.00
Group Total for Claim No: 15648757 $0.00 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $0.00
NUMBER OF CLAIMS IN PERIOD: 1
TOTALS IN PERIOD: $0.00 $0.00 $0.00 $0.00 $1.00 $0.00 $1.00 $0.00 $0.00 $0.00 $0.00
Loss Paid Med Paid Exp Paid Current
Loss Resv
Current Exp Resv
Current Med Resv
Gross Incurred
Expense Recovery
Deduct Recovery
Salvage Recovery
Subro Recovery SUB TOTALS for Policy Period: 05/11/2017 TO 05/11/2018
TOTAL NUMBER OF CLAIMS: 2
GRAND TOTALS: $0.00 $0.00 $0.00 $0.00 $2,501.00 $0.00 $2,501.00 $0.00 $0.00 $0.00 $0.00
Loss Paid Med Paid Exp Paid Current
Loss Resv
Current Exp Resv
Current Med Resv
Gross Incurred
Expense Recovery
Deduct Recovery
Salvage Recovery
Subro Recovery GRAND TOTALS
Page 2 of 2
Created by: Claims Activity as of 01/26/2018 Run Date: 1/27/2018 11:24:54AM
ABCD98569856 Hot Conditioned Air, Inc.
Insurance Assurance, Inc.
THE ULTIMATE INSURANCE COMPANY
