This application is required in addition to current ACORD application
Important Note: This application is not a representation that coverage does or does not exist for any particular claim or loss, or type of claim or loss, under any insurance policy issued by Travelers Company. Whether coverage exists or does not exist for any particular claim or loss under any such policy depends on the facts and circumstances involved in the claim or loss and all applicable wording of the policy actually issued.
GENERAL INFORMATION
Account Name / Account Number
Account Address / Effective Date
OPERATIONS
1. / Do you have any discontinued operations or have you operated in states other than those in which you currently operate? If yes, describe: / Yes No
2. / Do you have any non-construction operations? If yes, describe: / Yes No
3. / Percent of work you perform as a General Contractor? / %
4. / Percent of work you perform as a subcontractor? / %
5. / Percent of work you perform under design/build contracts? / %
6. / Type of work:
a. / New Construction / %
b. / Service/Repair / %
c. / Renovation Work / %
d. / Demolition / %
7. / Types of Projects: Indicate what percentage of your operation during the last five years involved any work (including site preparation) for the following types of project:
Percentage / Was any of this frame Construction?
a. / Apartments: / % / Yes No
b. / Student housing/dorms: / % / Yes No
c. / Military housing: / % / Yes No
d. / Condominiums: / % / Yes No
e. / Townhouses: / % / Yes No
f. / Retirement Communities: / % / Yes No
g. / Schools: / % / Yes No
h. / Government Buildings: / % / Yes No
i. / Hospitals: / % / Yes No
j. / Hotels: / % / Yes No
k. / Assisted Living Facilities: / % / Yes No
l. / Nursing Homes: / % / Yes No
m. / Single Family Homes: / % / Yes No
n. / All Other: / % / Yes No
EIFS
8. / Have you ever installed (or subcontracted the installation of) EIFS products? / Yes No
If yes:
a. / What percentage of work involves EIFS products? / %
b. / When was your last installation?
c. / How long have you been engaged in the installation of EIFS products?
d. / What percentage of EIFS work is installed by you? / %
e. / What percentage of EIFS work is installed by a subcontractor? / %
f. / What percentage of EIFS work is installed over wood substrate? / %
g. / Does a certified inspector inspect EIFS installation? / Yes No
h. / Describe EIFS quality control procedures:
i. / If you install, describe employees EIFS training and certification:
j. / If you subcontract, list subcontractor(s) used, their EIFS experience and their employee EIFS training and certification:
If you subcontract, are subcontractors policies reviewed for EIFS related limitations? / Yes No
PROJECT LIST AND FINANCIALS
Please include the following project lists and financial information:
9. / Projects being bid in excess of $250,000 costs.
10. / All projects in process.
11. / All projects completed within the last three years.
12. / Describe and list date of completion of all residential/habitational projects completed within the last 10 years (include location of project).
13. / Attach current audited financial statements.
SUBCONTRACTORS HIRED BY YOURSELF
14. / What percentage of work is subcontracted by you? / %
15. / List trades/type of work subcontracted by you
16. / Attach sample copy of contract used with subcontractors.
17. / Do your contracts require:
a. / Indemnification in your favor? / Yes No
b. / Waiver of subrogation in your favor? / Yes No
c. / You and owner be added as additional insureds? / Yes No
d. / Additional insured status to include completed operations? / Yes No
e. / Additional insured status to be primary and noncontributory? / Yes No
18. / Minimum Insurance Coverage and Limits required by your subcontractors:
a. / Commercial General Liability “occurrence” form? / Yes No
b. / Each Occurrence Limit / $
c. / General Aggregate Limit / $
d. / Products/Completed Operations Limit/Aggregate Limit / $
e. / Personal Injury/Advertising Injury Limit/Aggregate Limit / $
f. / Auto Liability Limits / $
g. / Employers Liability Limit (on WC) / $
h. / Umbrella Limits / $
19. / Do you normally use the same subcontractors? / Yes No
If no, do you put the majority of your subbed work out for bid? / Yes No
SAFETY ACTIVITIES
20. / Do you have a formal safety program? Please attach copy. / Yes No
a. / Name and title of personal responsible for safety:
b. / Percentage of time this person spends on safety responsibilities? / %
c. / Do you have a management accountability program? / Yes No
d. / Do you have a drug and alcohol testing program? / Yes No
e. / Do you maintain written records of safety activities? / Yes No
21. / Do you have a fleet management program? Please attach copy. / Yes No
If yes, does it include:
a. / Ordering Motor Vehicle Reports (MVRs) on all drivers? / Yes No
If yes, before hiring? / Yes No
How often after hired?
b. / Standards for an acceptable driver? / Yes No
c. / A policy on personal use of vehicles? / Yes No
d. / Cell phone use policy? / Yes No
QUALITY CONTROL PROGRAMS
22. / Do you have a written quality control program? Please attach copy. / Yes No
a. / Describe how you track change orders:
b. / Name and title of person responsible for quality:
Percentage of time this person spends on these responsibilities? / %
OTHER CONTRACTUAL RELATIONSHIPS
23. / Do you lease workers? If yes, attach copy of contract. / Yes No
24. / Do you rent equipment? If yes, attach copy of contract. / Yes No
a. / Describe types of equipment:
b. / Do you rent equipment with operator? / Yes No
PAYROLL/REVENUE HISTORY
25. / Payroll/revenue history for 5 prior years and projections for upcoming term:
Projected / 1st Prior / 2nd Prior / 3rd Prior / 4th Prior / 5th Prior
Direct Payroll
Total Revenue
Total Subcontracted Costs
Please read the statement applicable to your state. If your state and/or line of business are not listed, please read the statement applicable to All Other States. Then sign, date and return your application
ARKANSAS: 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: 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.
DISTRICT OF COLUMBIA: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.
FLORIDA: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
HAWAII: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both.
KENTUCKY: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.
LOUISIANA: 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.
MAINE: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.
MINNESOTA: A PERSON WHO SUBMITS AN APPLICATION OR FILES A CLAIM WITH INTENT TO DEFRAUD OR HELPS COMMIT A FRAUD AGAINST AN INSURER IS GUILTY OF A CRIME.
NEW JERSEY: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.
NEW MEXICO: 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 CIVIL FINES AND CRIMINAL PENALTIES.
NEW YORK (Non Auto): Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
OHIO: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD.
OKLAHOMA: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
OREGON: Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a false statement as to any material fact, may be violating state law.
PENNSYLVANIA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND CIVIL PENALTIES.
PUERTO RICO FRAUD WARNING: Any person who knowingly and with the intent to defraud, presents false information in an insurance request form, or who presents, helps or has presented a fraudulent claim for the payment of a loss or other benefit, or presents more than one claim for the same damage or loss, will incur a felony, and upon conviction will be penalized for each violation with a fine of no less than five thousand dollars ($5,000) nor more than ten thousand dollars ($10,000); or imprisonment for a fixed term of three (3) years, or both penalties. If aggravated circumstances prevail, the fixed established imprisonment may be increased to a maximum of five (5) years; if attenuating circumstances prevail, it may be reduced to a minimum of two (2) years.
TENNESSEE (Non WC): IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS.
VERMONT: Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance containing any materially false information or conceals for the purpose of misleading information concerning any fact material thereto, may be committing a crime, subjecting the person to criminal and civil penalties.
VIRGINIA: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
WASHINGTON: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
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.
ALL OTHER STATES: Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties. Not applicable in Nebraska.
FLORIDA REQUIREMENT: Producer’s License NO.
Applicant Signature / Date
Agent Signature / Date
© 2005 The Travelers Companies, Inc. All rights reserved.
58650 Rev. 7-05 Printed in U.S.A. Page 1 of 5