Artisan / Trade Contractors Product Application Form Page 2
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421. Loss information for the past three years: q None
Year
# of Claims
Incurred Amounts
Description of Claim
$
$
$
22. Indicate the operations conducted by the applicant by providing the payroll (including casual labor) for each trade performed by
the applicant:
Classification
Payroll
Classification
Payroll
Air conditioning systems
$
Interior decorators
$
Carpentry - residential <= 4 stories
$
Landscape gardening
$
Carpentry - interior
$
Lawn care services
$
Carpentry - commercial
$
Masonry
$
Carpentry shop only
$
Painting - exterior
$
Carpet, rug, furniture cleaning
$
Painting - interior
$
Ceiling or wall installation-metal
$
Painting - shop only
$
Door/Window installation
$
Paperhanging
$
Driveway/Parking/Sidewalk paving
$
Plumbing - commercial/industrial
$
Dry wall/Wallboard installation
$
Plumbing - residential
$
Electrical apparatus installation
$
Siding installation
$
Electrical contractors
$
Sign painting - inside buildings
$
Electrical work - within buildings
$
Sign painting - on buildings
$
Floor covering - not ceramic/stone
$
Tile/Stone/Marble work
$
Furniture or fixture installation
$
Tree pruning
$
HVAC - no LPG
$
Upholstering
$
House furnishing installation
$
Upholstering - shop only
$
Insulation work - mineral
$
Window cleaning
$
23. There are no operations in any classes other than those listed above
q True
q False
24. Describe the three largest jobs undertaken in the past three years:
Description
Location (City, State)
Cost
Duration
$
$
$
25. Does applicant need to name an entity on a waiver of subrogation?
q Yes
q No
If “Yes”, provide below information:
Name
Address (Street, City, State, Zip Code)
Interest
FRAUD STATEMENTS
Alabama, Arkansas, District of Columbia, New Mexico, Rhode Island and West Virginia: Any person who knowingly presents a false or fraudulent claim
for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and
confinement in prison.
Colorado Fraud Statement: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose
of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company
or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of
defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the
Colorado division of insurance within the department of regulatory agencies.
ATC 7/14 – USLI
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