Artisan Contractors - Supplemental Application Form
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1COLONY INSURANCE COMPANY
ARTISAN CONTRACTORS
General Agent Name
SUPPLEMENTAL APPLICATION
Insured:
Date ___________________
Owner/Partner 16,000– (TX – 20,000) $
Risk is a (% of each):
Employee Payroll:
$
General Contractor
_________________%
Uninsured Subcontractor Payroll:
$
Subcontractor
_________________%
Total Payroll:
$
Subcontractor Cost
$
Type of Work Performed
Total Receipts
$
Room Additions
________________%
Repair/Service Work
________________%
General Information
Structural Work
________________%
License # & Type held
_________
Remodeling Work
________________%
Years in Business:
_____
_________
Other
________________%
Years of Experience:
_________
Maximum # Of Stories
__________________
Maximum Depth below Grade_____________
Yes
No
Any Roofing Performed
Ground Up Construction
__ %
If Yes complete a Roofing Supplemental
% Residential ______ %
(new residential _____Yes _____No)
(Prohibit Commercial Roofing)
%Commercial ______ %Industrial ___________%
•
Type of work done by you and your employees:
Yes
No
Yes
No
•
Alarm monitoring?
Alarm monitoring subcontracted?
Yes
No
•
Any mobile equipment leased without operators?
•
Type of equipment leased? _______________________________________________ ____
•
Any snow plowing operations?
Yes
No Street Cleaning
Yes
No Public Streets & Roads?
Yes
No
•
Has the ins’d ever been involved in any construction of new residential properties i e. Custom homes,
Tract or Condo developments, apts or Town Homes in the past 10 years or will they do so in the future?
Yes
No
•
Have you ever been involved or are you involved in construction of residential room additions?
Yes
No
Yes
No ____% of total
Yes
No ____%
•
Any LPG work?
Any Floor waxing?
•
What precautions does the Insured take to properly ventilate the premises while applying or removing
varnish, lacquers, or glue while refinishing or working on floors or finishing/refinishing cabinets - _________
___________________________________________________________________________________ ____
•
List the last 3 jobs including the cost of those jobs.
Location
Type of Job
Job Receipts
$
$
$
Describe any losses:
SUBCONTRACTED WORK
•
What work are the subcontractors hired to do?
%
%
%
•
Are certificates of insurance obtained prior to subcontractors starting work?
Yes
No
Minimum Limits Required $
Yes
No
•
Are you named as an additional insured on the subcontractor’s policy?
Yes
No
•
Do subcontractors carry Worker’s Compensation
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
Clear Form
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