Vendors/contractors Insurance Application Form
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1Office of Insurance and Risk Management
Vendors/Contractors Insurance Application
(No Flat Cancellations – Please be sure of Request to Bind.)
VENDORS/CONTRACTORS REQUEST TO:
BIND COVERAGE
QUOTE COVERAGE
INDICATE WHICH COVERAGE IS BEING REQUESTED: GENERAL LIABILITY
GENERAL & PROFESSIONAL LIABILITY
CONTRACTORS PROGRAM:
Insurance & Risk Management Department, please complete the top section and submit with a copy
of the contract including scope of business to:
DRIVER ALLIANT (to Bind), Attention: Stephanie McBee, Assistant Account Administrator, Fax: (949) 251-1663
COVERAGE IS NOT IN FORCE UNTIL BINDER RECEIVED FROM COMPANY
DATE SUBMITTED: ___________________________
PUBLIC ENTITY: _________________________________________ FAX: _________________ CONTACT: _______________________
VENDOR/CONTRACTOR: ________________________________________________________ DATE: __________________________
VENDOR/CONTRACTOR MAILING ADDRESS: ________________________________________________________________________
VENDOR/CONTRACTOR CONTACT: _______________________________PHONE: ________________EMAIL: ___________________
DESCRIPTION OF CONTRACT: ____________________________________CONTRACT VALUE: ________________________________
SCOPE OF WORK: _____________________________________________________________________________________________
TERM OF CONTRACT: FROM: ________________ TO: _______________ HAZARD: ___________________ RATE: ________________
General Aggregate Increase to $2 Million Limit for a 10% additional premium (taxes/all fees not included)
Fire Damage Increase (Not Premises Liability Risk) $300 K for a flat fee (taxes/all fees not included)
PREMISES LIABILITY ONLY RISK (automatically increases Fire Damage Limit to $300,000). Please select square foot option below.
0-500 sq ft - $500
501-1000 sq ft - $650
1001-1500 sq ft -$800
Note: Fees charged do not include taxes and all fees.
PLEASE BIND THE ABOVE ACCOUNT EFFECTIVE (No Backdating): ________________________
Total Policy Premium:
$ ___________________
State Tax and Stamping Fee (3.225%):
$ ___________________
Certificate Fee:
$ 60.00_______________
Total Amount:
$ ____________________
PLEASE SUBMIT A COPY OF THE CONTRACT OR SCOPE OF BUSINESS.
For Consultants who are required to have Professional Liability. See section for General and Professional Liability coverage. If
Professional Liability is already in place, please provide a copy of the declaration page.
SEND TO: Insurance and Risk Management, 18111 Nordoff Street, Mail Drop 8284, Northridge, CA 91330-8284
Phone: (818) 677-2401, Fax (818) 677-5853
(THE QUOTING PROCESS CAN TAKE APPROXIMATELY 4-6 WEEKS)
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Parent category: Business