Roofing - Supplemental Application Form
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1COLONY INSURANCE COMPANY
ROOFING
General Agent Name
SUPPLEMENTAL APPLICATION
Insured: _____________________________________________________
Date:
Prohibited
Any Commercial/Industrial roofing
Torch down roofing
Any work on new, residential construction
Owner/Partner Payroll $_____________ # of Employees # ________
Employee Payroll $ ___________
Advise if the insured does any work other than roofing: _________________________________________
_______________________________________________________________________________________
Repair/Patching/Replacement ____________% Hot tar ______
%
Heat applied roofing _______ %
What type of materials do you use for the roofing?
Composition shingles
Wood shake
Tile
Rolled roofing
Metal
Foam
Other _____________________________________________________________________________
What is the maximum height of buildings you work on? __________ stories
Do you use scaffolding in the operation?
Yes
No
Annual cost of subcontracted work: $ ___________________
Check the type of work that is subcontracted out:
Waterproofing
Siding
Hot tar
Rain Gutters
Carpentry
Insulation
Other _____________________________________________________________________________
Are Certificates of Insurance (of equal limits) received on all subcontractors?
Yes
No
Are hold harmless agreements required for all work involving subcontractors?
Yes
No
Receipts for the previous three years: Year ________ Receipts ________
Year ________ Receipts ________
Year ________ Receipts ________
What are the safety precautions used by the applicant to avoid trip and fall claims in and around the
construction area? ______________________________________________________________________
______________________________________________________________________________________
What are the safety precautions used by the applicant to protect the roof and/or the interior of the structure
in the event of rain? _____________________________________________________________________
How are materials lifted to the roof? _______________________________________________________
How are roofs protected overnight? ________________________________________________________
List the last 3 jobs including the cost of those jobs:
Location
Type of Job
Job Receipts
________________________________ _____________________________
____________________
________________________________ _____________________________
____________________
________________________________ _____________________________
____________________
Describe any prior losses: _______________________________________________________________
_____________________________________________________________________________________
I hereby certify that all information is accurate to the best of my knowledge.
Applicant Signature:
Date:
Producer:
Date:
91F
Page 1 of 1
2005
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