CURRENT POLICY PERIOD
PROJECTIONS FOR UPCOMING POLICY PERIOD
If all of your subcontractors are adequately insured, please provide your estimated total costs for the next policy period below. (Including all labor and materials purchased by you or the subcontractor.)
Please advise of the following exposures owned by your company:
Please answer the following questions for all past, present or discontinued operations:
(Please provide details in the comments section at the end of this application to any questions below to which you responded “yes” except those noted.)
Do your operations include any of the following: (if not performed by an insured subcontractor)
The limits shown below are standard. If you would like different limits, please edit these fields accordingly. Our licensed representative will be happy to discuss your
limit options with you.
Occurrence (Other than Products Completed Operations)
Occurrence (Products Completed Operations)
Products Completed Operations Aggregate
Applicable in AL, AR, DC, LA, MD, NM, RI and WV: Any person who knowingly (or willfully)* presents a false or fraudulent claim for payment of a loss or benefit or knowingly (or willfully)* presents
false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. *Applies in MD only
Applicable in CO: 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.
Applicable in FL and OK: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or application containing any false, incomplete or misleading
information is guilty of a felony (of the third degree)*. *Applies in FL only
Applicable in KS: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer,
broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance or the rating of an insurance policy for personal or commercial insurance, or a claim for payment
or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for
the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act.
Applicable in KY, NY, OH and PA: 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 act, which is a crime and subjects such person to criminal and
civil penalties (not to exceed five thousand dollars and the stated value of the claim for each such violation)*. *Applies in NY only
Applicable in ME, TN, VA and WA: 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 and denial of insurance benefits. *Applies in ME only.
Applicable in NJ: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.
Applicable in OR: 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.
Applicable in PR: Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps or causes the presentation of a fraudulent claim
for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation by a fine of not less
than five thousand dollars ($5,000) and not more than ten thousand dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances [be] present, the
penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2) years.
This information is not an offer to sell insurance. Insurance coverage cannot be bound or changed via submission of this online application. No binder, insurance policy, change, addition, and/or deletion to insurance coverage may be obtained from this website, but same shall become effective only when confirmed directly by a licensed agent. Any proposal of insurance we present to you will be based upon the values developed and exposures to loss disclosed to us on this online application and/or in communications with us. Any pricing offered will be valid for not more than thirty days, and we reserve the right to make no pricing offer and to withdraw any price quoted. All coverages are subject to the terms, conditions and exclusions of the actual policy issued. Not all policies or coverages are available in every state. We agree to only use this information for insurance quoting purposes and not to distribute it to other parties. BY SUBMITTING THIS REQUEST YOU AGREE TO THESE TERMS AND CONDITIONS.