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Claims

 
Building Service Contractors

Insurance Program Application

Firm quote requires claims history for the last 3 policy years. please contact your current agent, and previous agent(s) if necessary, and request your "hard copy loss runs for all policies."

General Information       (Required *)

Date: * (mm/dd/yyyy)
Business Name: (incl Corp and T/A names): *
Contact Person: *
Title:
Mailing Address/Street:
City:
State:
Zip:
Location Address/Street:
City:
State:
Zip:
Phone: *
Fax:
E-Mail: *
Entity Type (Corp, Sole Prop, LLC, etc):
Yr Established:
Federal ID #:


Underwriting Questions
Type of building you occupy (office, retail strip mall, industrial, etc.)
# of Stories:
Construction (Frame, Masonry, Noncombustible, Fire Resistive, etc):
Sq Ftg You Occupy:
Approx Yr Built:
If bldg over 20 yrs old, Year(s) Updated for Wiring, Heating, Plumbing, Roof:


Policy Limits - We Will Quote Our Standard Program Limits Unless You Specify Other Limits Desired
Office Contents:
Unscheduled Mobile Equipment Limit (max $1,000 per item):
Scheduled Mobile Equipment (for individual items exceeding $1,000):
General Liability Limit: Auto Liability Limit:


General Liability — Underwriting Questions
Explain all "Yes" answers below.


Is a formal safety program in operation? Yes No Any exposure to flammables, explosives, chemicals? Yes No
Do you install, service, or demonstrate products? Yes No Do you provide guarantees, warranties, or hold harmless agreements? Yes No
Any exposure to radioactive/nuclear materials? Yes No Any operations involving storing, treating, discharging, applying, disposing, or transporting of hazardous material? Yes No
Do you lease employees to or from other employers? Yes No Have any crimes occurred or been attempted on your premises within the last three years? Yes No
Explain "Yes" answers here:


Automobile — Underwriting Questions
Explain all "Yes" answers below.


Do over 50% of employees use their autos in the business? Yes No Is there a vehicle maintenance program in operation? Yes No
Are any vehicles leased to others? Yes No Any vehicles customized, altered or have special equipment? Yes No
Do operations involve transporting hazardous material? Yes No Any vehicles used by family members? If so, identify below. Yes No
Do you obtain motor vehicle records for new drivers? Yes No Any drivers with moving traffic violations? Yes No
Explain "Yes" answers here:


Workers Compensation — Underwriting Questions
Explain all "Yes" answers below.


Do you have an Experience Modification Factor? Yes No If so, what is that factor and when is it effective?

Any work performed underground or above 15 feet? Yes No Are you engaged in any other type of business? Yes No
Group transportation provided? Yes No Any seasonal employees? Yes No
Do employees travel out of state? Yes No Are physicals required after offers of employment are made? Yes No
Are employee health plans provided? Yes No Do any employees predominantly work at home? Yes No
Any prior coverage declined, cancelled or non-renewed in the last 3 years? Yes No
Explain Yes answers here:


Umbrella — Underwriting Questions
Explain all "Yes" answers below.


Is bridge, dam, or marine work performed? Yes No Is contract or agreement made with customer? If so, attach copy Yes No
Do you own, rent, or otherwise use cranes or scaffolds? Yes No
Explain Yes answers here:


General — Underwriting Questions
Explain all "Yes" answers below.


Do employees work in pairs? Yes No Employees supervised on the job? Yes No
Are single-person jobs limited to experienced staff? Yes No Are periodic unannounced job site management checks performed? Yes No
Written applications completed by all prospective employees? Yes No Are references checked? Yes No
Does employment application ask about prior criminal acts? Yes No Are criminal background checks performed on all employees? Yes No
Describe below any loss control and safety measures in place to avoid employee injury, auto accidents, and customer property damage (driver training, loss prevention meetings, new hire training, etc.):
Explain "Yes" answers here:


Workers Compensation Exposures - Please review your current policy for all classes and codes
Class/Description Work Comp Code Estimated Annual Payroll(do not include owners) # FT Employees # PT Employees State
Commercial General Cleaning - Labor 9014 *
Carpet Cleaning ONLY 2585 *
Office - Inside 8810 *
Sales - Outside 8742 *
Other:
Other:
* These codes vary in some states. Please refer to your policy for the code that corresponds to the Class/Description shown.


Owners/Officers: List below all owners/officers of the business, whether active or inactive
Owner/Officer Name (1):
Title:
Duties(or indicate if inactive):
Annual Payroll: Include or Exclude?:
Owner/Officer Name (2):
Title:
Duties(or indicate if inactive):
Annual Payroll: Include or Exclude?:
Owner/Officer Name (3):
Title:
Duties(or indicate if inactive):
Annual Payroll: Include or Exclude?:
Owner/Officer Name (4):
Title:
Duties(or indicate if inactive):
Annual Payroll: Include or Exclude?:


Vehicle Schedule
If you have a separate listing, please click here to attach it to an email to us.
Year Make/Model Vehicle ID (Serial Number) Original Cost New Garaging City, State


Driver Schedule
If you have a separate listing, please click here to attach it to an email to us.
Driver Name(as it appears on license) Drivers License Number State Date of Birth


Insurance Carrier History
Coverage Company Date Expires How Long
with this
Company
Property & General Liability
Automobile
Workers Compensation
Umbrella

Claims History
A FIRM QUOTATION REQUIRES CLAIMS HISTORY FOR THE LAST 3 POLICY YEARS. PLEASE CONTACT YOUR CURRENT AGENT, AND PREVIOUS AGENT(S) IF NECESSARY, AND REQUEST YOUR "HARD COPY LOSS RUNS FOR ALL POLICIES."

Any Additional Comments

    





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