Contractors General Liability Supplemental Application/worksheet
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1Contractors General Liability Supplemental Application/Worksheet
(Attach to Commercial General Liability Application, ACORD 126-S)
Applicant’s Name
Email address:
SUPPLEMENTAL COVERAGES
Property Damage Extension Endorsement (CCC buy-back)
$
/ $
(Maximum sub-limit: $100/ $100)
Errors and Omissions Coverage
Yes____
No____
1. Type of contractor’s license and number:
Year license issued:
____________
2. List three latest projects completed, including cost: ___________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
3. Number of employees:
4. Account history for prior 3 years:
Payroll
Total Receipts
Total Subcontracted Cost
1st prior
2nd prior
3rd prior
5. Are you named as an additional insured on the subcontractors’ policies?
Yes
No
6. Are any additional insureds to be added to your policy?
Yes
No
Explain ___________________________
7. Indicate % of work performed:
New Construction
%
Remodeling
%
Repair
%
Commercial
%
Industrial
%
Residential Tract/ Subdivision
%
Spec Homes
%
Custom Homes
%
Townhouses
%
Other
%
(Describe):
8. How many homes per year do you “frame”?
9.
Maximum number of residences, condominiums, townhouses or apartments built during any 12-month period during
the last five years:
Residential Homes
Condos
__________
________Townhouses
Apartment Buildings
10.
Any work performed above three stories in height?
Yes
No
11.
Do you have Workers’ Compensation coverage in force?
Yes
No
Applicant Signature & Date
Producer Signature & Date
PA01-417(12/01)
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