Operations of Insured

• Number of years in business & experience:    
  
• Prior carrier?      
  
• Losses within the past 3 years:      
  
• Has insured been involved in any construction defect claims? If yes describe:      
  
• Employee payroll:      
  
• Number of employees:      
  
• Number of active owners:      
  
• Insured subcontractor costs:      
  
• Uninsured Subs used not under the direct supervision of the
• insured (1099 labor):      
  
• Annual gross sales:      
  
• CA only - Licensed? If so, continuous prior coverage in place for 5 full years or brand new license?      
  
• New Residential Work? If yes, custom homes only?     
  
• Remodeling Work:      
  
• Roofing? Describe:      

General Liability Limit requested

• Occurrence: $     
  
• Products/Completed Ops: $     
  
• General Aggregate: $     

Additional Insured(s) needed?

• If so, how many and what are their interest?    
• Special wording required?:      

Other Coverage Requested?    

Operations of Insured

 

Current & prior coverage information

• Current carrier:
  
• More than 3 losses in 3 years or any losses over $25,000?

General Liability Information:

• Limits Requested:
  • Each Occurrence:      
  • Aggregate:      
    
• Classification code(s)
  • Location/Code 1:       Basis:      
    
  • Location/Code 2:       Basis:      
    
  • Location/Code 3:       Basis:      

Any of the following? :

• Student Housing, Senior Housing, Subsidized Housing, Swimming Pool, Playgrounds, Courts, Mercantile Exposure?:     
• AI, Waiver of Subrogation, Non-owned Auto, etc?

Property Coverage info: Location 1

• Limits Requested
  • Building: Coins/Valuation:
  • BPP: Coins/Valuation:
  • BI/Rents: Coins/Valuation:
  • Other: Coins/Valuation:     
    
• Deductible Req:  
• Construction:      
• Year Built:      
• Updates: Copper Wiring?
• Square Feet      
  

Property Coverage info: Location 2

• Limits Requested
  • Building: Coins/Valuation:
  • BPP: Coins/Valuation:
  • BI/Rents: Coins/Valuation:
  • Other: Coins/Valuation:     
    
• Deductible Req:  
• Construction:      
• Year Built:      
• Updates: Copper Wiring?
• Square Feet      

Property Coverage info: Location 3

• Limits Requested
  • Building: Coins/Valuation:
  • BPP: Coins/Valuation:
  • BI/Rents: Coins/Valuation:
  • Other: Coins/Valuation:     
    
• Deductible Req:  
• Construction:      
• Year Built:      
• Updates: Copper Wiring?
• Square Feet      

Additional remarks/notes

Operations of Insured

 

Current & prior coverage information

• Current carrier      
  
• More than 3 losses in 3 years or any losses over $25,000?

General Liability Information:

• Limits Requested:
  • Each Occurrence:      
    
  • Aggregate:      
    
• Classification code(s)
  
  • Location/Code 1:       Basis:      
    
  • Location/Code 2:       Basis:      
    
  • Location/Code 3:       Basis:      

Any of the following?

• AI, Waiver of Subrogation, Non-owned Auto, etc?

Property Coverage Info: Location 1

• Occupancy & %:      
  
• Limits Requested
  • Building: Coins/Valuation:      
    
  • BPP: Coins/Valuation:      
    
  • BI/Rents: Coins/Valuation:      
    
  • Other: Coins/Valuation:      
    
• Deductible Req:      
  
• Construction:      
  
• Year Built:      
  
• Updates:      
  
• Square Feet      
  
• Alarm:      
  
• Commercial Kitchen/Fryers/Grill:      
  
• Length of vacancy:      
  

Property Coverage Info: Location 2

• Occupancy & %:      
  
• Limits Requested
  • Building: Coins/Valuation:      
    
  • BPP: Coins/Valuation:      
    
  • BI/Rents: Coins/Valuation:      
    
  • Other: Coins/Valuation:      
    
• Deductible Req:      
  
• Construction:      
  
• Year Built:      
  
• Updates:      
  
• Square Feet      
  
• Alarm:      
  
• Commercial Kitchen/Fryers/Grill:      
  
• Length of vacancy:     

Property Coverage Info: Location 3

• Occupancy & %:      
  
• Limits Requested
  • Building: Coins/Valuation:      
    
  • BPP: Coins/Valuation:      
    
  • BI/Rents: Coins/Valuation:      
    
  • Other: Coins/Valuation:      
    
• Deductible Req:      
  
• Construction:      
  
• Year Built:      
  
• Updates:      
  
• Square Feet      
  
• Alarm:      
  
• Commercial Kitchen/Fryers/Grill:      
  
• Length of vacancy:     

Additional remarks/notes

Operations of Insured

• Name of the Insured
• Exact Address of the Project     
  
• Describe exactly what is being done and/or built. Be sure to include the number of buildings being erected, number of stories and the corresponding square footage of the buildings. (For example, if town homes: How many units, buildings, etc. If renovation only, describe in detail the type of renovation – interior, exterior):      
   
• Total number of acres at this project to include any wetland/conservation area and acres that are not to be developed:
   
  
• Are there any water exposures such as lakes, ponds etc.?
  
  • If yes, enter type:      
    
  • Size:      
    
  • Owned by Insured?: No / Yes
    
• Is land being subdivided?
  • If Yes, into how many lots?    
• Describe buildings currently on the land:
  • Will they be demolished?
• Is the Insured involved in the construction of any buildings?
  • If Yes, enter the number of buildings: 
    
  • Number of stories:      
    
  • Square Footage:      
    
• Any pools being installed?: No Yes, please describe:  
• How long will the project take?
  
• What date will the project begin?
  
• If the project has already begun, please answer the following:
  
  • What has been completed?
  • What still needs to be completed?
• Total cost of this project:  
  
• Receipts to be generated from the project:
• Percent of work subcontracted:
• Who is the General Contractor (GC)?:      
• What are the GC’s limits (Must not be less than Insured’s)?
  
• Will the Insured be added as AI on the GC’s policy? (This is a must)

UNDERWRITING INFORMATION

• Event Dates      
• Description of Event (Attach copy of flyer or brochure)
• Estimated attendance per day      
• Total for all days event is held      
• Gross Sales $   
• Food or beverages sold or served by applicant? IIf yes, provide details.
• Alcoholic beverages on premises? If yes, are they served by applicant or other? Is liquor liability coverage in place?
• Seating arrangements – Describe (i.e., permanent, portable, bleachers, chairs, etc.) If portable, who does the erection?
• Setup – Describe all exposures (i.e., booths, stages, electrical, special effects, etc.) Who is responsible for the setup?    
• Security – Describe (i.e., guards - unarmed vs. armed, dogs, off-duty police, etc.) If guards are used, do they have their own insurance?     
• Parking facilities Yes/ No? Operated by: Applicant/ Others If others, do they have their own insurance? Is parking area Paved Dirt Other (describe)   
• Medical emergencies – describe how an emergency will be handled.
• Are certificates of insurance required from all subcontracted operations?
• Does the applicant use any mobile equipment? If yes, describe and give details of how it is used.      

ANIMAL EXPOSURE

• Are there animal rides? Yes No If yes, are animals hand lead?
• List the types of animals
• Describe area where rides are given (arena, roped off area, etc.)
• Is safety apparatus used? Yes No If yes, describe.  
• Is there a petting zoo? Yes No If yes, describe.  
• List the types of animals      
  
• How is it set up (fenced area, etc.)?      
  
• Is the area supervised?

AMUSEMENT DEVICES – Kiddie Type

• Provide a complete list of equipment.      
  
• Is applicant properly licensed to operate equipment?
• Are the rides supervised at all times?
• Does the vendor or subcontractor operate Kiddie rides?  

AMUSEMENT DEVICES – Other than Kiddie Type

• Operator must have insurance and provide a certificate of insurance with limits and coverage at least equal to those requested on this application.

DEMOLITION DERBY, MUD BOGS AND TRACTOR PULLS

• Provide description of facility (Attach diagram on separate sheet) including type of protection used to protect the spectators from flying debris, placement of barriers to keep vehicles a safe distance from spectators, etc.      

DOG RACES, HORSE RACES, RODEOS AND HORSE SHOWS

• Provide description of facility (Attach diagram on separate sheet)   
• Are spectators allowed in any area where animals are kept when not performing?
• Do livestock contractors have their own insurance?
• Is seating at least ten (10) feet from the arena?

FAIRS AND CARNIVALS

• Provide complete description of event (Attach diagram on separate sheet indicating location of each exhibit, booth, ride, event, etc.)

FIREWORKS EXHIBITION – SPONSOR’S RISK ONLY

• Pyrotechnicians must be licensed, have insurance and provide certificates of insurance with limits and coverage at least equal to those requested on this application.
• Are volunteers used to perform any duties at the exhibition?
• Spectators must be at least one hundred fifty (150) feet from where fireworks are being set off. Describe crowd controls used to maintain this distance.      
• Describe the duties performed by volunteers.   

MUSICAL CONCERTS

• Name of performer(s) and type of music      
  
• Do they have their own insurance?
• Describe seating, i.e., bleachers, grass, folding chairs, etc
• Is seating assigned?
  
• Type of venue. indoor outdoor. If outdoors, if facility designed to accommodate this type of event?

PARADES – SPECTATOR LIABILITY ONLY

• Provide complete description of parade including crowd control (Attach diagram of route and spectator areas on separate sheet.)      
• Provide number and type of floats.      
  
• Are there any animals in the parade? If yes, describe.      
  
• Are participants required to have their own insurance?

LIMITS – GENERAL LIABILITY (PER OCCURRENCE)

• General Aggregate (Other than Products/Completed Operations)
• Products & Completed Operations Aggregate
  
• Personal & Advertising Injury (Any One Person or Organization)
  
• Each Occurrence
  
• Damage to Premises Rented to You (Any One Premises)
  Medical Expense (Any One Person)

CERTIFICATE RECIPIENTS / ADDITIONAL INTERESTS

• Name And Address
• Relationship to Applicant
• Additional Insured
• Certificate

PRIOR CARRIER HISTORY & LOSS INFORMATION

• Prior Carriers (Last Three Years):
  • Year
  • Carrier
  • Policy Number
  • Limits
  • Premium
• Loss History (Last Five Years)
  • Date of Loss
  • Type of Loss
  • Description of Loss
  • Amount Paid
  • Reserve
• Has the applicant been cancelled or non-renewed in the last three years? If yes, Explain.