Artisan / Trade Contractors Product Application Form

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CARRIER:
Artisan / Trade Contractors Product Application
This application may only be used for eligible Artisan/Trade Contractor classes listed on page two of this application that do not have more than $50,000 in
subcontracted work. If the applicant has more than $50,000 in subcontracted work, please complete and submit our Artisan/General Contractors Supplemental
Application (CSA 4/07).
1. Applicant name: __________________________________________________________________________________________________
2. Form of business:
q Individual
q Corporation
q Partnership
q LLC
q Other _____________________________
3. Mailing address: __________________________________________________________________________________________________
City: _____________________________________________________ State: ____________________ Zip: ________________________
4. Location address: ________________________________________________________________________ q
Same as mailing address
City: _____________________________________________________ State: ____________________ Zip: ________________________
5. Audit contact: ______________________________________________________________ Phone number: _________________________
6. Web site address: __________________________________________________________ E-mail address: _________________________
7. Limit:
q $100/$200
q $300/$300
q $300/$600
q $500/$500
q $500/$1,000
q $1,000/$1,000
q $1,000/$2,000
8. Projected annual sales:$ _________________________
9. How long has the applicant been in business? _________________________________________
10. List all states where construction activity is planned: ____________________________________
11. For applicants located in Connecticut, New Jersey, New York or Pennsylvania -
q N/A
q Yes
q No
Is any work perfored in the following boroughs of New York: Bronx, Brooklyn, Manhattan, or Queens?
12. Projected cost of subcontracted work (includes labor and materials) $ ______________________
If subcontractors are used, the applicant requires certificates of insurance evidencing
general liability coverage
q True
q False
13. The applicant will need additional insured endorsements
q True
q False
14. The applicant has no past, present or future operations in Alaska, Colorado, Louisiana or West Virginia
q True
q False
15. The applicant does not have any past allegations or claims involving construction defect
q True
q False
16. The applicant has not been in business for more than 12 months with no prior coverage
q True
q False
17. The applicant has never, or will not during our policy term, be involved in projects in any capacity for the
construction of new apartments, condominiums, townhouses or tract homes
q True
q False
18. Insurance coverage has not been cancelled or non-renewed in the past three years (not applicable in MO)
q True
q False
19. No past, pending or planned bankruptcy or judgment for unpaid taxes against the named insured
or any officer, partner, member or owner of the applicant individually within the past five years
q True
q False
20. The applicant does not perform any:
a.
Wood floor sanding or refinishing
q True
q False
b.
Exterior operations in excess of four stories or above 50 feet from ground level
q True
q False
c.
Installation of overhead garage doors
q True
q False
d.
Alarm monitoring or security system installation, service, maintenance or repair work
q True
q False
e.
Rigging work or use of cranes
q True
q False
f.
Ice or snow treatment/removal services
q True
q False
g.
Fire, water, soot, mold, asbestos or any other type of property damage remediation
q True
q False
h.
Fire suppression or sprinkler work
q True
q False
i.
Work involving medical facilities (other than doctor’s office), surgical facilities, nursing homes or
assisted living facilities during applicant’s time in business or planned for our policy term
q True
q False
j.
Boiler system installation, service or repair
q True
q False
k.
Work on foundations or chimneys
q True
q False
l.
Waterproofing operations
q True
q False
m. Pollution or abatement work
n.
Demolition work (except incidental non-load bearing interior work)
q True
q False
ATC 7/14 – USLI
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