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ROOFING CONTRACTORS SUPPLEMENTAL …

Please send submissions to: ROOFING CONTRACTORS SUPPLEMENTAL APPLICATION SUBMISSION REQUIREMENTS Complete signed / dated SUPPLEMENTAL Application(s) Completed ACORD applications Currently valued insurance company loss runs for the current policy period plus four (4) prior years Description of all claims Sample contracts entered into with sub-contractorsACCOUNT INFORMATION Applicant Name: contractor s License(s) #: Mailing address: City: State: Zip: Website: www. Risk Management Contact: Risk Management s Phone: Risk Management Email: SECTION I GENERAL INFORMATION in business under current name:Years other names which the Applicant has conducted (s) in which the Applicant will do or has done operations in New York?Yes No If yes,% in New York City, Long Island and Westchester County % in remainder of state Any operations in Colorado?Yes No If yes, % of residential work of operations:General contractor : % Sub- contractor : % Prime contractor : % of work to be performed by the Applicant or on their behalf:Construction types: Residential: % + Commercial/ Industrial: % =100% Indicate Split of RESIDENTIAL work ConstructionSingle Family Tract % (Check here if none ) Single Family Custom % Condo/Townhome/Townhouse % Commercial Including Apartments % Solar panel Installation % Other: % , Repair & Replacement Single Famil

Please send submissions to: submissions@tmsic.com. ROOFING CONTRACTORS SUPPLEMENTAL APPLICATION . SUBMISSION REQUIREMENTS • Complete signed / dated Supplemental Application(s)

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Transcription of ROOFING CONTRACTORS SUPPLEMENTAL …

1 Please send submissions to: ROOFING CONTRACTORS SUPPLEMENTAL APPLICATION SUBMISSION REQUIREMENTS Complete signed / dated SUPPLEMENTAL Application(s) Completed ACORD applications Currently valued insurance company loss runs for the current policy period plus four (4) prior years Description of all claims Sample contracts entered into with sub-contractorsACCOUNT INFORMATION Applicant Name: contractor s License(s) #: Mailing address: City: State: Zip: Website: www. Risk Management Contact: Risk Management s Phone: Risk Management Email: SECTION I GENERAL INFORMATION in business under current name:Years other names which the Applicant has conducted (s) in which the Applicant will do or has done operations in New York?Yes No If yes,% in New York City, Long Island and Westchester County % in remainder of state Any operations in Colorado?Yes No If yes, % of residential work of operations:General contractor : % Sub- contractor : % Prime contractor : % of work to be performed by the Applicant or on their behalf:Construction types: Residential: % + Commercial/ Industrial: % =100% Indicate Split of RESIDENTIAL work ConstructionSingle Family Tract % (Check here if none ) Single Family Custom % Condo/Townhome/Townhouse % Commercial Including Apartments % Solar panel Installation % Other: % , Repair & Replacement Single Family Tract % (Check here if none )Single Family Custom % Condo/Townhome/Townhouse % Residential Condo Conversion % Commercial (including apartments) % Solar Panel Installation % Other: % TOTAL =100% Indicate Split of COMMERCIAL / INDUSTRIAL Work (Including Apartments) below.

2 Construction% , Repair & Replacement% TOTAL =100% ROOFING CONTRACTORS SUPPLEMENTAL ApplicationPage 1 of 6 2018 Philadelphia Consolidated Holding Payroll, Sub- contractor Cost and Gross SalesExposure Basis Estimates for next 12 Months 1st Prior Year 2nd Prior Year 3rd Prior Year 4th Prior Year Gross Sales $ $ $ $ $ Commercial ROOFING Payroll $ $ $ $ $ Residential ROOFING Payroll $ $ $ $ $ Sheet Metal Payroll $ $ $ $ $ Cost of Sub-Contracted Work $ $ $ $ $ Other Payroll $ $ $ $ $ SECTION II ROOFING OPERATIONS the height of buildings on which the Applicant or its sub- CONTRACTORS perform work:Average Number of Stories: Maximum number of the Applicant have formal fall protection safety program?Yes No attach a copy of your fall protection of ROOFING work to be performed by the Applicant or on its behalf by sub-contractorsHot Tar % Torch Down % Modified Bitumen (Hot) % Modified Bitumen (Cold) % Shingle % Tile % Metal Panel % Vegetative Roof System % Other (describe): % torches, hot air welders, heating kettles or heating tankers used?

3 Yes No If yes, please explain the process and safety precautions used to prevent fires during andafter work fire extinguishers available at all job sites?Yes No the Applicant perform Fire Watch prior to leaving the job site?Yes No If yes, how all work involving the use of torches performed by employees who have completed theNational ROOFING CONTRACTORS Association s Certified ROOFING Torch Application Program(CERTA)?Yes No If no, please explain employee training and supervisory practices with respect of torch andwelding the Applicant or its sub- CONTRACTORS abate/remove asbestos shingles?Yes No roof openings covered to prevent weather infiltration after work hours?Yes No If yes, please explain methods and supervisory the Applicant or its sub- CONTRACTORS use scaffolding?Yes No If yes, is there any rental of scaffolding to others?Yes No all jobs inspected by a job supervisor or foreman upon completion of work, but beforeleaving the job site?

4 Yes No the Applicant a member of the national ROOFING CONTRACTORS Association?Yes No the Applicant rent cranes or other equipment from others?Yes No If yes, provide details including whether rented with or without operator and thecorresponding cost of such rentals: ROOFING CONTRACTORS SUPPLEMENTAL ApplicationPage 2 of 6 2018 Philadelphia Consolidated Holding the Applicant carry separate Wrap-Up programs / OCIP (Owner-Controlled InsurancePolicy)?Yes No the Applicant hire independent sub- CONTRACTORS to perform work on its behalf?Yes No If no, please disregard Questions 13 through 17 the Applicant execute written contracts including indemnification clauses in its favorwith all sub- CONTRACTORS working for the Applicant?Yes No the Applicant have written contracts with independent CONTRACTORS that require theymaintain Commercial General Liability insurance including the Applicant as an AdditionalInsured?

5 Yes No If yes, what is the minimum limit required: $ the Applicant obtain certificates of insurance from sub- CONTRACTORS ?Yes No If yes, how long does the Applicant retain copies of contracts and certificates of all jobs inspected by a job supervisor or foreman upon completion of work, but beforeleaving the job site?Yes No type of work is sub-contracted to other?Roof Tear Off Other: SECTION III OTHER OPERATIONS the Applicant have operations other than ROOFING construction?Yes No If yes, are those operations covered by other insurance?Yes No payrolls by classes of other construction work to be performed by the Applicant oron its behalf for the upcoming $ Excavation $ Plumbing $ Boiler $ Fire Suppression $ Seismic Retrofitting $ Bridge Building $ Gas Main $ Sewer/Water $ Carpentry $ Grading $ Solar $ Concrete $ Hazardous Material $ Steel (Ornamental) $ Crane Rental $ HVAC $ Steel (Structural) $ Demolition $ Insulation $ Street/Road $ Earthquake Repair $ Mechanical $ Supervisory Only $ EIFS / Synmthetic Stucco $ Painting $ Tanks $ Electrical $ Plastering $ Waterproofing $ Other (describe): $ the Applicant use casual, volunteer, or temporary labor?

6 Yes No If yes, are such workers covered by the Applicant s workers compensation insurance?Yes No the Applicant hire employees or independent CONTRACTORS through employmentagencies?Yes No If yes, who is responsible for maintaining workers compensation insurance for such the employment agencies responsible for performing background checks on suchworkers including verification of United States citizenship, valid green cards, or valid workvisas?Yes No SECTION IV JOB LIST AND CLAIM INFORMATION list the largest projects planned for the upcoming term currently or Value: $ Value: $ Value: $ Value: $ Value: $ list the five largest projects in the past five Value: $ Value: $ Value: $ Value: $ Value: $ ROOFING CONTRACTORS SUPPLEMENTAL ApplicationPage 3 of 6 2018 Philadelphia Consolidated Holding there been any losses, claims or suits against the Applicant or its sub- CONTRACTORS inthe past five years?

7 If yes, please explain: Yes No the Applicant or its sub- CONTRACTORS been accused of faulty construction in thepast five years?Yes No the Applicant or its sub- CONTRACTORS been accused of breaching a contract in thepast five years?Yes No the Applicant or its sub- CONTRACTORS ever filled any Mechanic Liens in the past fiveyears?Yes No the Applicant or its sub- CONTRACTORS been accused of imported drywall claims inthe past five years?Yes No the Applicant aware of any circumstance, incident or accusation arising out of work itperformed or its sub- CONTRACTORS which may give rise to a claim?Yes No Please explain any yes answers from the section above:SECTION V CONTRACTORS POLLUTION LIABILITY past, current or planned involvement mold remediation work performed by the Applicant or its sub- CONTRACTORS ?Yes No demolition?Yes No / remediation of lead, asbestos, radon, PCBs or other hazardous materials?

8 Yes No or removal or work on fuel tanks or pipelines?Yes No , underpinning, cofferdam or caisson work?Yes No repair or retrofitting work?Yes No or ground water remediation?Yes No emergency response or landfill contracting work?Yes No , mining or petroleum production or hydro fracking work?Yes No If yes, please there coverage in place? If so, advise expiring contractor s pollution coverage:Limits: $ Deductible / SIR: $Premium: $ No Any water intrusion / mold claims?If yes, please Applicant encounters leaks, how are they handled and documented? Applicant have a water intrusion management plan? If yes, please No SECTION VI - DRONES the Applicant employ the use of drones during the course of its operations?Yes No describe how drones are used during the course of the Applicant s drones are used, is the Applicant the pilot or does the Applicant hire a sub- contractor topilot them? (Please check below)Operator Sub- contractor Not Applicable the Applicant obtain certificates of insurance from sub- CONTRACTORS hired topilot the drones?

9 N/A Yes No training has the Applicant completed to pilot the drones? ROOFING CONTRACTORS SUPPLEMENTAL ApplicationPage 4 of 6 2018 Philadelphia Consolidated Holding STATEMENT AND SIGNATURE SECTIONS The Undersigned states that he/she is an authorized representative of the Applicant and declares to the best of his/her knowledge and belief and after reasonable inquiry, that the statements set forth in this Application (and any attachments submitted with this Application) are true and complete and may be relied upon by Company * in quoting and issuing the policy. If any of the information in this Application changes pri or to the effective date of the policy, the Applicant will notify the Company of such changes and the Company may modify or withdraw the quote or binder. The signing of this Application does not bind the Company to offer, or the Applicant to purchase the policy. *Company refers collectively to Philadelphia Indemnity Insurance Company and Tokio Marine Specialty Insurance Company.

10 FRAUD NOTICE STATEMENTS 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 AND SUBJECTS THAT PERSON TO CRIMINAL AND CIVIL PENALTIES (IN OREGON, THE AFOREMENTIONED ACTIONS MAY CONSTITUTE A FRAUDULENT INSURANCE ACT WHICH MAY BE A CRIME AND MAY SUBJECT THE PERSON TO PENALTIES). (IN NEW YORK, THE CIVIL PENALTY IS NOT TO EXCEED FIVE THOUSAND DOLLARS ($5,000) AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION). (NOT APPLICABLE IN AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN, NM, OK, PA, RI, TN, VA, VT, WA AND WV). APPLICABLE IN AL, AR, AZ, DC, LA, MD, NM, RI AND WV: ANY PERSON WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES OR CONFINEMENT IN PRISON.


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