Transcription of COLONY SPECIALTY INSURANCE ARTISAN …
1 Contractors PDQPage 1 of 112/15/2010 COLONYSPECIALTYINSURANCEARTISANCONTRACTO RSG eneral Agent NameSUPPLEMENTALAPPLICATIONI nsured:Date _____Owner/Partner 16,000 (TX 20,000) $Riskisa(% of each):Employee Payroll:$General Contractor_____%Uninsured Subcontractor Payroll:$Subcontractor_____%Total Payroll:$Subcontractor Cost$TypeofWorkPerformedTotal Receipts$Room Additions_____%Repair/Service Work_____%GeneralInformationStructural Work_____%License # & Type held_____Remodeling Work_____%Years in Business:_____Other_____%Years of Experience:_____Maximum # Of Stories _____Maximum Depth below Grade_____Any Roofing PerformedYesNoGround Up Construction__ %If Yes complete a Roofing supplemental % Residential _____ % (new residential _____Yes _____No)(Prohibit Commercial Roofing)%Commercial _____ %Industrial _____% Type of work done by you and your employees: Alarm monitoring?YesNoAlarm monitoring subcontracted?YesNo Any mobile equipment leased without operators?YesNo Type of equipment leased?
2 _____ ____ Any snow plowing operations?YesNo Street CleaningYesNo Public Streets & Roads?YesNo Has the ins d ever been involved in any construction of new residential properties i e. Custom homes,Tract or Condo developments, apts or Town Homes in the past 10 years or will they do so in the future?YesNo Have you ever been involved or are you involved in construction of residential room additions?YesNo Any LPG work?YesNo____% of totalAny Floor waxing?YesNo____% What precautions does the Insured take to properly ventilate the premises while applying or removingvarnish, lacquers, or glue while refinishing or working on floors or finishing/refinishing cabinets - _____ ____ List the last 3 jobs including the cost of those of JobJob Receipts$$$ Describe any losses:SUBCONTRACTED WORK What work are the subcontractors hired to do?%%% Are certificates of INSURANCE obtained prior to subcontractors starting work?YesNoMinimum Limits Required $ Are you named as an additional insured on the subcontractor s policy?
3 YesNo Do subcontractors carry Worker s CompensationYesNoIherebycertifythatall information isaccurateto Signature:Date:Producer:Date:Agent Name: _____ Agency Name: _____ Email Address: _____ Phone Number: _____ Please select your option below.
