Contractor Remodel/Repair Insurance Application (Complete in addition to ACORD General Liability Application)

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Contractor Remodel/Repair Insurance Application

(Complete in addition to ACORD General Liability Application)

Date:

NAME OF APPLICANT (include DBA if applicable):

State/Area of Operations: Web site Address: Provide details of all your operations:

Do you have other business ventures for which coverage is not requested? ... Yes No If yes, explain and advise where insured:

ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE NOT APPLICABLE 1. Applicant Operations: Check Classification Schedule on Pages 3-5 for Eligibility

Number of Owner/Partners: Payroll: No. of Employees:

Show by Class: Operation is: (% of each) Type of Work:

Class: Payroll $ General Contractor % Residential/Repair % Class: Payroll $ Artisan Contractor % Residential/Remodeling % Class: Payroll $ Subcontractor % Residential Renovation %

Total 100 % Commercial %

Uninsured Subcontractors: Cost $ Industrial %

Other: Payroll $ Total 100 %

Insured Subcontractors: Cost $

2. Receipts/Sales: Current Year: Previous Year: Two Years Ago: 3. Describe equipment used in operations:

Cranes/Cherry Pickers/Lifts—Maximum height: 4. List three current or planned projects:

Customer Name and Project Description Cost of Project Duration of Project

a.

b.

c.

5. List five largest jobs in the last three years:

Customer Name and Project Description Cost of Project Duration of Project

a.

b.

c.

d.

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6. Have you acted in the capacity of a General Contractor in the past? ... Yes No If yes, provide details:

7. Liability Controls:

a. Do you use a written contract with customers?... Yes No If no, explain when not required:

b. Do you use a written contract with subcontractors?... Yes No If no, explain when not required:

c. Do your contracts contain a hold harmless agreement in your favor? ... Yes No d. Do you obtain certificates of liability insurance from all subcontractors? ... Yes No

If yes, minimum limits required:

e. Do you obtain certificates of Workers Compensation insurance from all subcontractors? ... Yes No f. Are you added as an additional insured on the subcontractors’ liability policies? ... Yes No g. Do you have Workers’ Compensation coverage in force? ... Yes No h. Do you provide architectural or engineering design services? ... Yes No

If yes, explain:

Do you carry Errors & Omissions coverage for these services? ... Yes No i. Are you a contraction/project manager or consultant? ... Yes No 8. Other:

a. Have you been involved in any claims in the past three years? ... Yes No If yes, explain:

b. Are you listed as an approved/preferred contractor for an insurance company, ServiceMagic, Angie’s List or Signature Contractors.com? If yes, please list: _______________________________________________________________________ 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.

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 cri minal and civil penalties.

APPLICANT’S NAME AND TITLE:

APPLICANT’S SIGNATURE: _________________________________________________ DATE: (Must be signed by active owner, partner or executive officer.)

AGENT’S SIGNATURE: _________________________________________________________ DATE: NAME AND PHONE NUMBER OF INDIVIDUAL TO CONTACT FOR INSPECTION/AUDIT:

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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.

Eligible Classes of Business

Applications for business classes not listed below will be declined.

Class Code Class Category Description

13590 Glass Dealers and

Glaziers

Misc Installation &

Ser-vicing Cutting and installation of glass. Heights over 2 1/2 stories are ineligible

14913 Locksmiths Misc Installation &

Ser-vicing Alarm installation is ineligible

59914 Metal, decorative,

workshop Metal Work

Ornamental and non-structural work. Welding of trailer hitches or structur-al support welding is ineligible.

91111 Air Condition

Sys-tems Installation Air Conditioning

Sales and installation, servicing or repair of air conditioning systems or equipment. This classification also applies to risks engaged only in instal-lation, servicing or repair of air conditioning systems or equipment. No heating systems (rate heating under Heat/AC class 95647). No refrigera-tion or cold storage work. No sales or display rooms. SUBMIT - all risks with crane exposures.

91150

Appliance & Acces-sories Installation, Service of Repair

Misc Installation & Ser-vicing

Appliance Installation Commercial – No residential, apartment work ok. No cutting, slicing equipment. No LPG manufacturing, storage or distribution. Includes Service and Repair.

91155

Appliance & Acces-sories Installation, Service of Repair

Appliance and Accessories – Installation, service and repair of household appliances & accessories. No commercial appliances. Not intended for Household TV or radio receiving set installation, service or repair. No LPG manufacturing, storage or distribution. Includes Service and Repair.

91341 Carpentry Interior Carpentry

Interior – Finish carpentry, Includes woodwork, trim, countertop (no tile), wooden doors, cabinet installation, shelving, floors, laminate floors, win-dows and hardwood or parquet flooring. Not applicable to contractors engaged in any other carpentry operation at the same job or location. No abatement work.

91342 Carpentry NOC Carpentry

Carpentry - Commercial only. Includes commercial tenants improvements & betterments, repair & replacement. Non-structural remodeling & repair only. All roofing and foundation work must be subcontracted. No exterior work on buildings exceeding three stories. No abatement work

91343 Carpentry Shop Only _{– Woodworking} Carpentry Installation, service and repair of residential, light industrial and

commer-cial interior cabinets 91405

Carpet, Rug Furniture or Upholstery Clean-ing – on Customer’s Premises

Cleaning

Carpet, Rug, Furniture or Upholstery Cleaning – on customer premises only, no shop exposure. No water extraction except in conjunction with carpet cleaning. Add RVIC 963.

91436 Acoustical Tiling Ceiling or Walls Ceiling or wall installation - metal or acoustic only

91481 Chimney cleaning

(Chimney Sweep) Cleaning

Chimney, fireplace, wood stove, air duct and dryer duct cleaning only. No Repair

91551

Communication Equipment Installa-tion

Telephone Equipment Installation - wiring, cables & circuits for telephone and communications equipment operating at less than 50 volts. Work within buildings only. 3 stories or less.

91560 Concrete Masonry / Concrete

Flat cement or concrete work for driveways, Parking Areas, Patios and Sidewalks only. No structural work, including foundation repair, drilling and any crane exposures. No bridge, dam, tunnel or sewer construction, gun-nite or shot-crete work, pile driving, tunneling, subway construction, cais-son or cofferdam work, or highway construction. No playground work.

91629 Debris Removal Cleaning Construction site clean up. No hazardous materials, No salvage

opera-tions, No asbestos or mold removal, or remediation. 91746

Door, Window or Assembled Millwork Installation - Metal

Door/millwork/window installation - service, repair and installation of ga-rage doors are okay. Submit automatic door work including gaga-rage doors. No Window Work. 92215 Driveway, Parking Area or Sidewalk Paving or Repair Masonry / Concrete

Driveway or Sidewalk – No public/private street, road or highway work. No grading, filling or excavation other than incidental to driveway and sidewalk paving.

92338 Drywall or Wallboard

Installation Ceiling or Walls

Drywall or Wallboard installation. No asbestos or insulation. Painting of drywall must be rated separately with painting class code 98305.

92478 Electrical Work -

Within Building Electrical

Includes installation or repair of electrical fixtures and appliances and incidental outside work. It does not include installation of alarms or alarm systems, electrical machinery or auxiliary apparatus. No Fiber Optic cable or cell phone tower work.

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94276 Fence Erection Con-tractors

For risks that only install or erect fences. No swimming pool, playground, child-safety or electrically charged fencing. No manufacture of metal fences—erection only with no welding exposure.

94569

Floor Covering Instal-lation - Not Ceramic Tile or Stone

Installation of carpeting and laminate. Not Ceramic or Stone. Harwood floor installation must be rated using Carpentry – Interior class code 91341.

95125 Furniture fixture

in-stallation

Installation and repair of household furnishings including window treat-ments, draperies and shades. Household appliance installation and repair is not included. No furniture delivery operations.

95625 Handyman Janitorial

For a person who is not licensed in a particular trade or trained as a pro-fessional artisan, but is in the business of being hired to do a variety of miscellaneous work for others, usually involving minor repairs in a house-hold environment. No roofing. No subcontracted work.

95648

Heat and Air Condi-tion System Installa-tion, Servicing or Repair

Air Conditioning

Installation of air conditioning, and furnaces, service and repair duct work as well as service and installation of low pressure residential boilers for hot water heating systems. Rigging of cooling units on roofs, asbestos abatement handling and LPG, butane or propane gas work are ineligible. SUBMIT if any crane exposures

96053 House Furnishing _{Installation – NOC} Misc Installation &

Ser-vicing

House Furnishing Installation – Includes installation of pictures, mirrors, window treatments and closet organizers. No furniture repair or moving services.

96410 Insulation Ceiling or Walls

Includes installation or application of acoustical or thermal insulating ma-terial in buildings or within building walls. Class applies only when insula-tion or acoustical work is performed as a separate operainsula-tion, not part of or incidental to any other construction operation performed at same job loca-tion. No asbestos, formaldehyde products or polyurethane framing opera-tions.

96611 Interior Decorators Decorators

This category applies to the contractor who decorates office and residen-tial interiors. This classification does not include the actual contracting work performed by or for the Insured.

96816 Janitorial Janitorial

Janitorial - COMMERCIAL OFFICES ONLY - No industrial sites, residen-tial exposures, model homes, retail work or sales of chemicals or cleaning supplies. No debris removal other than incidental to office cleaning. Floor waxing only after normal business hours - add 10% surcharge. No floor waxing for 24-hour operations. No risks with propane floor waxers. No supermarkets or superstores. No more than 15% floor waxing. $500 PD Deductible per claim. Add RVIC 963.

97047 Landscaping Gardening

Landscape Maintenance & Gardening— (1) Basic landscape/lawn care service-mowing ; (2) Landscape Installation. Includes laying out grounds, planting trees, shrubs, flowers or lawns, and interior landscaping. Over-the-counter fertilizer/weed control. No nursery, agricultural or industrial irrigation systems. NO pesticides, herbicides or tree trim/removal. Deck construction (use 91342), decorative retaining walls (use 97447), No Pools, ponds. No excavation. Residential and commercial property work only. No work along any roads or highways. If any sprinkler system instal-lation or work add the appropriate plumbing classification and premium. No interior sprinkler system work of any type.

97447 Masonry Masonry / Concrete

Includes cutting & laying of bricks, block, stone and other unit masonry or clay product and mortar work. Retaining walls over 4 feet not allowed BUT perimeter wall over 4 feet ok. No street, road or highway walls or work. NO exterior work on buildings exceeding 3 stories, chimney or cast-in-place concrete work. Includes swimming pool tile work if above the water line only.

98111

Office Machine or Appliances – Installa-tion, InspecInstalla-tion, Re-pair

Office Machine Installation, inspection, adjustment or repair includes shop operations. Add RVIC 963.

98304 Painting Exterior - 3

Stories or less Decorators

Exterior-Buildings & appurtenant structures only, including walk-ways/fences, surface preparation and faux/texture painting. NO water-proofing, exterior work on buildings exceeding 3 stories or roof painting. No work on tanks, street and road, towers or bridges.

98305 Painting Interior Decorators Bathtub refinishing ok – No exterior/No waterproofing. Includes faux and

interior decorative painting operations.

98344 Paperhanging Decorators Includes surface preparation, covering walls and ceilings with wallpaper,

fabric, vinyl or other wall coverings.

98449 Stucco/Plastering Decorators

This category applies to residential, commercial or light industrial plaster-ers limited to plaster and stucco application and repair up to 2 1/2 stories. No artificial or synthetic (E.I.F.S) stucco work or application. Includes metal lath work for stucco operations.

98482 Plumbing –

Commer-cial Plumbing

Plumbing Commercial – No fire sprinklers, liquefied petroleum gas (LPG), septic tank, excavation, swimming pools, process piping, public utilities, hospitals or industrial work, hot water or steam/boiler work. Water softener installation ok. Acceptable operations: breaking and repair of concrete to

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install pipes. No main line work (sewer, gas, water).

98483 Plumbing –

Residen-tial Plumbing

Plumbing Residential – Water softener installation, okay to break concrete & repair to install pipes, lay sewer line/pipe drain and use ditch witch for underground lines. Lawn sprinklers installation ok. No main line sewer, gas, or water. No LPG. No interior sprinkler system work of any type. No swimming pool operations.

98636

Refrigeration Equip-ment Installation / Service

Refrigeration Equipment - Installation, service, repair of commercial refri-geration systems. No wholesale cold storage work, manufacturing, indus-trial, or processing work. Incidental LPG work ok (up to 15% of annual receipts).

98806 Septic Tank System

Maintenance Cleaning Cleaning only No installation, service or repair.

98884 Sheet metal work –

Outside Metal Work

Installation of ornamental and non-structural work only. No more than two stories. No roofing.

98967 Siding Installation Ceiling or Walls

Installation of vinyl or aluminum siding and gutters for residential and commercial buildings up to 2 1/2 stories. Includes installation of screen enclosure.

99650 Television or Radio

Receiving Set Instal-lation or Repair

Misc Installation &

Ser-vicing Residential only, no commercail work

99709

Tents or Canvas Goods – Erection, Removal or Repair (includes Awnings)

Misc Installation &

Ser-vicing Erection, Removal or Repair (includes Awnings)

99746 Tile - Stone Marble _(Interior) Misc Installation & Ser-_vicing

Installation and repair of ceramic tile, stone, marble, mosaic or terrazzo to floors, walls countertops. No swimming pools or roofs. Exterior construc-tion work shall be separately classed and rated as ―Masonry‖.

99827 Upholstery Decorators Includes incidental furniture refinishing or repairing.

99969 Welding or Cutting Metal Work Ornamental and non-structural work only. No stairs, trailer hitches or

structural support welding

99975 Window Cleaning (no