OWNERS/CONTRACTORS PROTECTIVE LIABILITY APPLICATION

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

  1. Name of Designated Contractor:

  Check all that applies: General Contractor General Manager Managing Agent

  Mailing Address:

Contract/Project No.:

If applicable, explain:

Watercraft/Aircraft Exposure:

Storing of Inflammable gases, liquids and explosives:

Hazardous waste removal or installation:

Drilling:

Blasting:

Scaffolding:

Construction or repair of oil or gas fields, pipelines, refineries, power lines, bridges, tunnels or elevated streets, roads or

highways:

Any work at or on former landfills or dump sites:

Underpinning or soil-stabilization operations:

*Must be answered.

  3. Limits of Coverage:

Aggregate Limit:

Occurrence Limit:

  4. Completed Contract Price:

  5. Terms of Contract (Outlined in Job Specifications):

Proposed Starting Date:

Job term in Calendar Days: Working Days:

Completion Date (indicate none if not shown in job specifications):

  6. Type of Subcontractors and Percent Subcontracted:

      a. %

      b. %

c. %

d. %

e. %

                                                                                                                         Total Subcontracted:   %

  7. Details of Any Hold Harmless Agreements:

  8. General Liability Program:

a. Contractor Primary Excess/Umbrella

Limits:

Term: 

Carrier:

If coverage is written, certificates of insurance will be required.

b. Subcontractor(s) Primary Excess/Umbrella

Limits:

Term: 

Carrier:

If coverage is written, certificates of insurance will be required.

ATTACH ANY CONTRACT OR INDEMNIFICATION AGREEMENT BETWEEN OWNER AND CONTRACTOR.

FRAUD WARNINGS AND ATTESTATION:

FRAUD WARNING: Any person who knowingly and with the 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 purposes of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties.

FRAUD WARNING (APPLICABLE IN TENNESSEE 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.

FRAUD WARNING APPLICABLE TO NEW YORK APPLICANTS: 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 be subject to civil penalty not to exceed five thousand dollars and the stated value of the claim for the violation.

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 NAME AND TITLE:

APPLICANT SIGNATURE:____________________________________________________ DATE:______________

(Signature of active Officer/Director/Partner or Owner)

PRODUCER’S SIGNATURE:____________________________________________________ DATE:______________