Applicant's Name

Agency Name

Address

Agent

Address

Location

Email

Web Site Address

Phone

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 (Specify)

LIMITS OF LIABILITY REQUESTED

PREMIUMS

General Aggregate

$

Premises/Operations

Products & Completed Operations Aggregate

$

$

Personal & Advertising Injury

$

Products

Each Occurrence

$

$

Damage To Premises Rented To You (any one premise)

$

Other

Medical Expense (any one person)

$

$

Other Coverage, Restrictions, and/or Endorsements:

Total

                                                              Deductible

$

$

A.

Applicant is a (% of each):

General contractor

%

Subcontractor

%

Developer

%

Construction manager/Consultant

%

Owner/Builder

%

B.

States/area of operations:

Radius of operations from main location: miles.

C.

Describe all operations in detail:

D.

Length of time in business: years.

Years of experience:

Are you licensed?

No Yes

Type of license and no.:

Year license issued:

Length of time in business operating under the name shown above: years or new venture.

Have you operated or been licensed under any other name(s) during the past ten (10) years?

No Yes

If Yes, provide prior name and describe type of operations:

Name

Describe Operations

E.

Total number of employees?

F.

Indicate % of operations involving:

1.     

New construction

%

Remodeling

%

Demolition

%

Repair

%

Other (explain below)

%   (Must total 100%)

Explain other:

2.

Commercial new construction

%

Commercial remodeling

%

Industrial

%

Institutional

%

Residential* new construction

%

Residential* remodeling

%

Apartments

%

Commercial Condominiums

%  (Must total 100%)

(*If Residential Construction--Condos/Townhouses (including conversions)

%;

Single family or residential dwellings

%;

If Residential Remodeling--Interior work only

%;

Ground-up construction

%)

G.

Have you been involved as a General Contractor in the building of Residential Homes, Condo-

miniums, or Townhouses in the past ten (10) years?

No Yes

If yes, indicate maximum number built during any twelve (12) month period, maximum at any one project/development

site and expected maximum number to be built during next twelve (12) months.  (For these purposes a duplex is

equivalent to two single family residences; a triplex equals three homes, etc.)

No. Residential Homes

No. any one Project/

Development Site

No. Condominiums/

Townhouses

Next 12 months

Prior Year:

Prior Year:

Prior Year:

Prior Year:

Prior Year:

Prior Year:

Prior Year:

Prior Year:

Prior Year:

Prior Year:

H.

Do you have a formal home warranty program?

No Yes

If yes, please give details:

I.

Do you have model homes?

No Yes

If yes, give no.:

Location:

J.

List all major projects completed within the past five years, including work in progress and planned projects.

(List project name, date, project description, location, and revenues):

K.

Indicate percentage of payroll for each type of construction work performed by your employees:

Airports

%

Gas Mains

%

Sewer

%

Asbestos Removal

%

Insulation

%

Soil Stabilization

%

Blasting

%

Maintenance

%

Steel (ornamental)

%

Bridges/Elevated Roads

%

Masonry

%

Steel (structural)

%

Carpentry

%

Mechanical

%

Street/Road

%

Communication Lines

%

Mold & Spore Remediation

%

Supervisory Only

%

Concrete

%

Oil or Gas Fields

%

Swimming Pools

%

Drilling

%

Painting

%

Tunneling

%

Earthquake Reinforcement

%

Pipeline/Water Main

%

Underpinning

%

EIFS

%

Plastering

%

Waterproofing

%

Electrical

%

Plumbing

%

Water Restoration

%

Excavating

%

Power Lines

%

Wrecking/Demolition

%

Fire Proofing

%

Process Piping

%

Other (describe)

%

Fire Restoration

%

Removal/Installation of

Underground Tanks

%

Framing of Buildings

%

Roofing

%

L.

Account history for prior five years and projected current year:

Year

Payroll

Total

Revenue

Subcontracted Cost

Cost of Labor, Fees,

Commissions +

Cost of Materials &

Equipment Rental =

Total Subcon-

tracted Cost

Current

1st Prior

2nd Prior

3rd Prior

4th Prior

5th Prior

M.

Are certificates of insurance obtained from subcontractors?

No Yes

Minimum Limits Required $

Do you use uninsured subcontractors?

No Yes

If yes, percentage of total subcontracted cost: %

N.

Are written contracts obtained from all subcontractors which include a hold harmless clause in

your favor?

No Yes

If no, explain when not required:

O.

Are you named as an additional interest on the subcontractors' policies?

No Yes

P.

Do you normally use the same subcontractors?

No Yes

If no, do you put all subbed work out for bids?

No Yes

Q.

Indicate type of construction work performed by your Subcontractors: (Indicate percentage of total subcontracted costs)

Airports

%

Gas Mains

%

Sewer

%

Asbestos Removal

%

Insulation

%

Soil Stabilization

%

Blasting

%

Maintenance

%

Steel (ornamental)

%

Bridges/Elevated Roads

%

Masonry

%

Steel (structural)

%

Carpentry

%

Mechanical

%

Street/Road

%

Communication Lines

%

Mold & Spore Remediation

%

Supervisory Only

%

Concrete

%

Oil or Gas Fields

%

Swimming Pools

%

Drilling

%

Painting

%

Tunneling

%

Earthquake Reinforcement

%

Pipeline/Water Main

%

Underpinning

%

EIFS

%

Plastering

%

Waterproofing

%

Electrical

%

Plumbing

%

Water Restoration

%

Excavating

%

Power Lines

%

Wrecking/Demolition

%

Fire Proofing

%

Process Piping

%

Other (describe)

%

Fire Restoration

%

Removal/Installation of

Underground Tanks

%

Framing of Buildings

%

Roofing

%

R.

Is any work done involving systems that provide:

Medical and/or industrial life support     Process piping     Dams/levees

S.

Does work require monitoring by:

Certified inspectors     Resident inspectors     Part-time     When called

T.

Any work performed above two stories in height from grade?

No Yes

Maximum number of stories:

U.

Any work performed below grade?

No Yes

Maximum depth: ft. % of total work

V.

Is scaffolding owned, rented or erected?

Are other contractors at job site allowed to use it?

No Yes

W.

Any work performed in the past using Exterior Insulation and Finish Systems (EIFS)?

No Yes

If yes, explain:

X.

Do you have a formal safety program in operation?

No Yes

Please explain and/or provide a copy:

Y.

Have you ever built or do you intend on building on hillsides, slopes, former landfills/dumps or

in subsidence areas?

No Yes

If yes, explain:

Percent of grade %

Prior testing (geological, topical)?

No Yes

If yes, explain:

Which geological survey engineering firm do you use?

Underpinning?

No Yes

Any past subsidence lossses?

No Yes

If yes, explain:

Z.

Do you or any of your employees hold a Real Estate Agent's license?

No Yes

If yes, has Professional Liability Coverage been obtained?

No Yes

Limit of Liability: $

AA.

Does applicant have other business ventures for which coverage is not requested?

No Yes

If yes, explain and advise where insured:

BB.

Any mobile equipment leased from others?

No Yes

If yes, from whom?

Lease basis?

Operators provided?

No Yes

Type of equipment leased?

CC.

Do you own any Vacant Land? (Raw land with no developmental or improvement activity, held only for

investment or possible development more than twelve (12) months in the future.  No buildings on property.)

No Yes

If yes, is property zoned:  Residential          Commercial/Retail/Industrial or other

No. of Acres

No. of Lots

Location Description

DD.

Do you own any Real Estate Development Property? (Land with improvements-streets, roads,

utilities, etc completed or under construction)

No Yes

If yes, is property zoned:  Residential          Commercial/Retail/Industrial or other

If zoned residential, provide location descriptions and number of lots at each development.

No. of Acres

No. of Lots

Location Description

EE.

Do you hold other persons' property for service, storage, or repair?

No Yes

If yes, explain:

FF.

Any underground storage tanks?

No Yes

If yes, when inspected and by whom?

GG.

Any employees working under:

U.S. Longshoremen's and Harborworkers' Act?

No Yes

Jones Maritime Act?

No Yes

If yes, what percent of payroll? %       Give city and state:

HH.

Does applicant have Workers' Compensation coverage in force?

No Yes

II.

Does applicant lease employees from others?

No Yes

Does applicant lease employees to others?

No Yes

JJ.

Dollar value of average job completed: $

KK.

Are any operation insured elsewhere by an owner-controlled insurance program (OCIP), also

referred to as wrap insurance?

No Yes

If yes, provide details:

LL.

During the past three years, has any company ever cancelled, non-renewed, declined or refused

issue similar insurance to the applicant? (Not applicable in Missouri)

No Yes

If yes, explain:

MM.

List all active owners, partners and executive officers and their job duties/responsibilities:

NN.

Have you ever had a construction Defect loss/claim or been involved in a class action Construction

Defect suit?

No Yes

If Yes, and loss or suit is older than five years, provide details:

Date of

Loss

Description of Loss

Amount Paid

Amount Reserved

Claim Status

(Open or Closed)

PRIOR CARRIER INFORMATION - FIVE YEAR PERIOD

Year:

Year:

Year:

Year:

Year:

Carrier

Policy No.

Total Premium

LOSS HISTORY - FIVE YEAR PERIOD

Indicate all claims or losses (regardless of fault and whether or not insured) or occurrences that may give rise to claims for

the prior five years.

Date of

Loss

Description of Loss

Amount Paid

Amount Reserved

Claim Status

(Open or Closed)

SCHEDULE OF HAZARDS

Loc.

No.

Classification

Class

Code

Premium Bases:

(s) Gross Sales

(p) Payroll

(a) Area   (t) Other

(c) Total Cost

Terr.

Rate

Premium

Prem./Ops.

Products

Prem./Ops.

Products

Authorized Applicant's Representative (Name and Phone number of individuals to contact for inspection/audit):

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:

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.

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.

I/We hereby declare that the above statements and particulars are true and I/We agree that this application shall be the basis of the contract with the insurance company.

APPLICANT'S SIGNATURE: _______________________________________________

DATE: ______________________

AGENT NAME: _______________________________________________

AGENT LICENSE NUMBER: ____________________

                                                                                                           (Applicable to Florida Agents Only.)

IOWA LICENSED AGENT (if applicable): _________________________________________________________________

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