PROPOSED EFFECTIVE DATE: From To 12:01 A.M., Standard Time at the address of the Applicant

Applicant Is: Individual  Corporation   Partnership    Joint Venture   Limited Liability Company   Other 

State/Area of Operations:

Do you have other business ventures for which coverage is not requested?.............................................. No Yes

PLEASE ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE.”

1. Applicant Operations:

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

(The state minimum payroll of at least one Owner/Partner/Officer must be included in the payroll estimate at policy issuance.)

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:

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

6.  Have you acted in the capacity of a General Contractor in the past?................................................ No Yes

7. Any past or current operations on new condominiums or townhouses/townhomes?......................... No Yes

If yes, provide details:

8. Indicate percentage of total operations performed by you or subcontractors for the following:

9. Any work on hillsides/slopes (over fifteen percent [15%] grade)?................................................. No Yes

        If yes, percentage of operations:........................................................................................................ %

10.  Any work at landfills?.................................................................................................................... No Yes

       If yes, percentage of operations:.............................................................................................................%

11.  Any work performed above two stories in height from grade?....................................................... No Yes

       Maximum number of stories:

12. List the subcontracted trades used and the percentage of total operations:

 
13.  Are any operations insured elsewhere by an owner-controlled insurance program (OCIP), also
      referred to as wrap insurance?......................................................................................... No Yes

14. Liability Controls:

a.  Do you use a written contract with customers?............................................................................. No Yes

    If no, explain when not required:

b.  Do you use a written contract with subcontractors?....................................................................... No Yes

    If no, explain when not required:

c.  Do your contracts contain a hold harmless agreement in your favor?............................................. No Yes

d.  Do you obtain certificates of insurance from all subcontractors?................................................... No Yes

e.  Are you added as an additional insured on the subcontractors’ liability policies?............................ No Yes

      f.  Do you have Workers’ Compensation coverage in force?.............................................................. No Yes

g.  Do you provide architectural or engineering design services?........................................................ No Yes

    Do you carry Errors & Omissions coverage for these services?...................................................... No Yes

h.  Are you a contraction/project manager or consultant?.................................................................. No Yes

     i.  Have you been involved in any claims involving construction defects?.............................................. No Yes

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 WARNINGS

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 criminal and civil penalties. Not applicable in Nebraska, Oregon and Vermont.

FRAUD WARNING (APPLICABLE IN TENNESSEE, VIRGINIA AND WASHINGTON):

It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.

NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

NOTICE TO OHIO APPLICANTS: Any person who knowingly and with intent to defraud any insurance company 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 criminal and civil penalties.

NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Notice To Florida Applicants: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony in the third degree.

Notice To Maine Applicants: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.

NOTICE TO MARYLAND APPLICANTS: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

NOTICE TO OKLAHOMA APPLICANTS: Any person who knowingly, and with intent to injure, defraud or deceive any
insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony

FRAUD WARNING APPLICABLE IN THE STATE OF NEW YORK:

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 shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

APPLICANT’S NAME AND TITLE:

APPLICANT’S SIGNATURE:_____________________________________________________________ DATE:________________

PRODUCER’S SIGNATURE:_____________________________________________________________ DATE:________________