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Commercial Insurance Underwriter

Commercial Insurance Underwriters, Inc.
A Surplus Lines Agency
www.ciusgf.com
901 E. Saint Louis St. #205
Springfield, MO. 65806-2537

CONTRACTORS APPLICATION

Applicant's Name		Agency Name
(*If more than one entity, attach separate sheet with description of each entity's operations, relationship to each other and ownership.)
Address		Agent
		Address
Location
		Email
Web Site Address		Phone

All questions must be answered in full. Application must be signed and dated by the applicant.

Proposed Policy Period to

Insured is Individual Partnership Corporation Joint Venture Other

Location #1

Location #2

Location #3

UNDERWRITING INFORMATION

Years in Business?

Years of Experience in this field?

Your contractor's license number #

Type of license

3.	Indicate the percent of each type of work performed.

Type	Commercial	Residential	Industrial	% of Total Operations
New Construction	%	%	%	%
Renovation	%	%	%	%
Real Estate Developer	%	%	%	%

4.	Indicate the percentage of work you perform as a General Contractor or as a Subcontractor:

(a) General Contractor %

(b) Subcontractor %

5.	Indicate the percentage of work on a typical project performed by the following:

(a) Your Employees %

(b) Subcontractors under your supervision %

If residential construction, how many homes per year?

Total # of homes in project

7.	Have you ever been involved in the construction or remodeling of apartments, townhouses, condominiums,
	tract homes or planned multi-unit developments?

	If yes, please provide the types of projects, specific locations, total values, number of units per project and year you
	worked on them.

Do you have a written safety program?

	Describe what safety precautions are in place

	How do you protect the general public from potential injury?

Is jobsite security provided at night?

	If yes, please describe

	(If more information, attach separate sheet.)

10.	What is the maximum height of buildings you work on? (# of stories)

11.

Does a foreman or qualified individual inspect all jobs upon completion?

12.

Do you perform any out of state work?

	If yes, in what states and provide details of work performed

	(If more information, attach separate sheet.)

13.

Have you ever or do you currently perform work in AZ, CA, CO, NV, NY, OR, UT or WA?

	If yes, please describe

14.

Have you ever used, sold, installed or removed asbestos?

	If yes, explain in detail

15.

Do you draw plans, designs or specifications?

	If yes, explain in detail

16.

Do you lease equipment to others with or without operators?

	If yes, describe equipment and forward copy of lease agreement.

17.

Do you employ a soil engineer?

If no, do you hire an independent soil engineer?

If yes, does he name you as an Additional Insured?

18.

Do you offer warranties? If yes, attach copies of warranty

19.

Do you have Mobile Equipment that travels over public roads?

20.

Do you perform or subcontract fire restoration and/or water remediation work?

21.	Do you or have you had any past, present or discontinued operations involving storing, treating, discharging, applying,

disposing, or transporting of hazardous material (e.g. landfills, wastes, fuel tanks, etc.)?

22.

Do you lease employees to or from other employers?

23.

Do you have a labor interchange with any other business or subsidiaries?

24.

Have you operated under any other name(s)?

If yes, list name, address, years in operation, state of operation and exposures.

Name

Address

Years in

Operation

State of

Operation

Exposures

25.

Do you perform work below grade?

If yes, what is the percentage of work % and Depth

26.

Do you now or have you ever built on hillsides, slopes, landfills or other terrain susceptible to subsidence?

	Describe

27.

Are you involved in any operations outside of the construction industry?

	Describe

28.	Have you ever been involved in or are you aware of pending litigation against any named insured concerning construction

defect or fungus/mold claims?

	Describe

29.	Number of executive supervisors?

30.	Indicate below the construction experience of your executive supervisors

Name	Years of Experience	Estimated Payroll	Largest Job Supervised	Years with Company

31.	Complete the following, if applicable

Number of Model Homes:

Development Property: acres

32.

Are you a subsidiary of another entity or do you have any subsidiaries?

33.

Any exposure to flammables, explosives, chemicals?

34.

Any operations sold, acquired, or discontinued in last 5 years?

35.

Have you been active in or are you currently active in joint ventures?

36.

Any bankruptcies, tax or credit liens against you in the past 5 years?

	Explain all yes responses:

SPECIAL HAZARDS

Do any of your operations involve the following?

Use of cranes

Blasting

Use of tower cranes

Length of booms: (# of ft.)

Shoring or underpinning

EIFS (Exterior Insulation and Finish Systems)

Pile driving

Demolition of structures (other than interior)

Caisson or cofferdam work

Structural alterations

10.

Other Special Hazards

	Explain all yes responses:

CONTROLLING THE SUBCONTRACTORS EXPOSURE

If you NEVER hire subcontractors, please check here

Are certificates of insurance required from subcontractors?

Do your subcontractors carry coverage or limits less than yours?

If yes, what are the minimum limits you accept?

3.	Are written contracts including a hold harmless clause in your favor obtained from all subcontractors? (A copy of the

contract is mandatory to bind coverage.)

Are you names as additional insured on the subcontractors' policy?

How long are Certificates of Insurance kept?

Until job ends One year Other

If other is checked, provide details

	Explain all yes responses:

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 on premises)	$
	Medical Expense (Any one person)	$

TYPE OF WORK PERFORMED

Please indicate whether the following trades are:

E - performed by your employees or S - performed by subcontractors

Description	E	Annual Payroll	S	Annual Cost	Description	E	Annual Payroll	S	Annual Cost
Bridge construction					Insulation
Carpentry					Interior demolition
Concrete					Landscaping
Debris removal					Masonry
Drilling					Painting
Drywall					Parking lot paving
Electrical					Plumbing
Excavation					Roofing
Framing					Street paving
Grading					Stucco
Guard rail installation					Other
HVAC					Other

EXPERIENCE

1.	List your gross sales for the last three years.

	Year 20	Gross sales $
	Year 20	Gross sales $
	Year 20	Gross sales $

2.	What is your anticipated gross sales for this term? $

CERTIFICATE RECIPIENTS / ADDITIONAL INTERESTS

Name And Address	Relationship to Applicant	Additional Insured	Certificate

LIST FIVE (5) OF YOUR LARGEST JOBS IN THE LAST FIVE (5) YEARS:

Location	Description of Job	Job Cost	Project Duration	Project Completion Date

LIST FIVE (5) OF YOUR LARGEST PROJECTS PLANNED FOR THE COMING YEAR:

Description	Estimated Job Cost	Estimated Project Duration

ADDITIONAL INFORMATION OR COMMENTS:

PRIOR CARRIER HISTORY % LOSS INFORMATION:

Has the applicant been cancelled or non-renewed in the last three years? If yes, Explain.

Prior Carriers (Last Three Years):
Year	Carrier	Policy Number	Limits	Premium

LOSS INFORMATION

-Obtain hard copy Company loss runs with a valued date within the last 90 days.

3 year loss runs for risks with up to $2,500,000 in sales.
5 year loss runs for risks with more than $2,500,000 in sales.

Loss History (Attach Separate Sheet if Necessary)
Date of Loss	Type of Loss	Description of Loss	Amount Paid	Reserve

This application shall not be binding unless and until confirmation by the Company or its duly appointed representatives has been given, and that a policy shall be issued and a payment shall be made, and then only as of the commencement date of said policy and in accordance with all terms thereof. The said applicant hereby covenants and agrees that the foregoing statements and answers are a full and true statement of all the facts and circumstances with regard to the risk to be insured, and the same are hereby made the basis and conditions of the insurance and a warranty on the part of the Insured.

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.

FRAUD STATEMENT

To Insureds in the States of:

Alabama, Alaska, Arizona, California, Connecticut, Delaware, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Maine, Massachusetts, Maryland, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, New Hampshire, Nevada, North Carolina, North Dakota, Oregon, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, West Virginia, Wisconsin, Wyoming:

NOTICE: In some states, 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, for the purpose of misleading, conceals information concerning any fact material thereto, my commit a fraudulent insurance act which is a crime in many states. Penalties may include imprisonment, fines, or a denial or insurance benefits.

Arkansas

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 my be subject to fines and confinement in prison.

Colorado

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 my 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 policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claiming with regard to a settlement or award payable for insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

District of Columbia

WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.

Florida

Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of claim containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

Kentucky

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance 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.

Louisiana

New Jersey

Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

New Mexico

New York

Any person who knowingly and with intent to defraud any insurance company or other person files an application for commercial insurance or a statement of claim for any commercial or personal insurance benefits containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, and any person who, in connection with such application or claim, knowingly makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, damage or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or an insurance company 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 value of the subject motor vehicle or stated claim for each violation.

Ohio

Any person who, with intent to defraud or knowing that he/she is facilitation a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

Oklahoma

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

Pennsylvania

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 act, which is a crime, and subjects such person to criminal and civil penalties.

Rhode Island

NOTICE: Under Rhode Island law, there is a criminal penalty for failure to disclose a conviction of arson. In some states, 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, for the purpose of misleading, conceals information concerning any fact material thereto, may commit a fraudulent insurance act, which is a crime in many states.

Virginia

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.

Washington



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Producer's Signature	Date


_____________________________________________	_____________________________________________
Applicant's Signature	Date

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