Umbrella / Excess Application

Applicant's Name*
Phone Number*
Email Address*
Location Address*
Location Address Line 2
City*
State*
Zip*
Mailing Address (if different from the above)
Mailing Address Line 2
Mailing City
Mailing State
Mailing Zip
Time in Business*
Please specify time in business
Years of Experience*
Please specify years of experience
Licensed?*
- Yes
- No
Years of License*
Please specify years of experience
License Number*
Kind of License (select all that apply)*
- Residential Contracting
- Commercial Contracting
- Plumbing
- Electrical
- HVAC
- Gas
- Asbestos/hazardous waste remediation
- Other
Please specify kind of license
Any previous/current license in another state?
- Yes
- No
If so, list state(s)
Percentage of Operations
General Contractor % Subcontractor % Construction Manager % Developer % With Penalty Clause (for a fee only) %
Are there any other operations owned, operated, or managed by you?
- Yes
- No
If yes, please explain
Is coverage in place elsewhere for these operations?
- Yes
- No
Does any of your construction management work involve supervision of subs whose contracts and payments are not directly under your control?
- Yes
- No
If yes, please explain
Radius of operations from main location*
States worked in*
Payroll of owners, officer, and partners active at job sites or performing supervisory duties $*
Payroll of employees other than owners, officers, partners, and clerical $*
Cost of leased, temporary, staffing service, casual labor (if not included above) $*
Total payroll $*
Do you employ any licensed architects, surveyors, engineers, Real Estate agents or brokers?
- Yes
- No
If yes, please explain
Do you have any prior or planned jobs covered under “wrap-up” or OCP policies?
- Yes
- No
Explain

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List the percentage of work you have done or plan to do in the following categories
Overall Operations*
Commercial % Public Works % Residential % Other %
Commercial*
New % Remodel %
Commercial*
Industrial % Institutional % Mercantile % Office % Remodeling – Structural % Remodeling – Nonstructural % Other %
Residential*
New % Remodel %
Residential*
Apartments % Condominiums/Townhouses % Custom Homes % Tract Homes % Remodeling – Structural % Remodeling – Nonstructural % Other %
Have you ever been or are currently involved in any residential project exceeding six (6) homes/units?
- Yes
- No
If yes, please explain

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Please provide your gross sales for each of the 5 past years and an estimate for the next 12 months:
5th Prior Year*
Payroll Receipts Subcontractors Cost
4th Prior Year*
Payroll Receipts Subcontractors Cost
3rd Prior Year*
Payroll Receipts Subcontractors Cost
2nd Prior Year*
Payroll Receipts Subcontractors Cost
Last Year*
Payroll Receipts Subcontractors Cost
Projected next 12 months*
Payroll Receipts Subcontractors Cost

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Describe your three largest projects currently underway or planned for the next year, including values:
Project #1*
Start Date End Date Value $ Description
Project #2*
Start Date End Date Value $ Description
Project #3*
Start Date End Date Value $ Description

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Describe your four largest projects over the past five years, including values:
Project #1*
Year Completed Value $ Description
Project #2*
Year Completed Value $ Description
Project #3*
Year Completed Value $ Description
Project #4*
Year Completed Value $ Description
Project #5*
Year Completed Value $ Description

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Complete the following table as applicable (DO NOT LEAVE ANY FIELDS BLANK) :
Most Common Classifications
Air Conditioning/Heating
Subbed Cost $ Subbed Cost % Employee Payroll $ Employee Payroll % None
Alarm Systems
Subbed Cost $ Subbed Cost % Employee Payroll $ Employee Payroll % None
Carpentry – Dwellings
Subbed Cost $ Subbed Cost % Employee Payroll $ Employee Payroll % None
Carpentry – Interior
Subbed Cost $ Subbed Cost % Employee Payroll $ Employee Payroll % None
Carpentry – Other
Subbed Cost $ Subbed Cost % Employee Payroll $ Employee Payroll % None
Concrete Construction/Repair – Driveways, Sidewalks or Parking Areas
Subbed Cost $ Subbed Cost % Employee Payroll $ Employee Payroll % None
Concrete Construction/Repair – Foundations, Flat Work / Tiltup Work
Subbed Cost $ Subbed Cost % Employee Payroll $ Employee Payroll % None
Drywall/Wallboard Installation
Subbed Cost $ Subbed Cost % Employee Payroll $ Employee Payroll % None
Electrical Work – Within Buildings
Subbed Cost $ Subbed Cost % Employee Payroll $ Employee Payroll % None
Electrical Work – Other
Subbed Cost $ Subbed Cost % Employee Payroll $ Employee Payroll % None
Excavating/Grading of Land
Subbed Cost $ Subbed Cost % Employee Payroll $ Employee Payroll % None
Insulation
Subbed Cost $ Subbed Cost % Employee Payroll $ Employee Payroll % None
Painting
Subbed Cost $ Subbed Cost % Employee Payroll $ Employee Payroll % None
Plumbing – Residential
Subbed Cost $ Subbed Cost % Employee Payroll $ Employee Payroll % None
Roofing – Residential
Subbed Cost $ Subbed Cost % Employee Payroll $ Employee Payroll % None
Supervisor Only
Subbed Cost $ Subbed Cost % Employee Payroll $ Employee Payroll % None
Secondary Classifications
Earthquake Reinforcement
Subbed Cost $ Subbed Cost % Employee Payroll $ Employee Payroll % None
Electrical Work – Other than Residential
Subbed Cost $ Subbed Cost % Employee Payroll $ Employee Payroll % None
Masonry – (EIFS Work-synthetic stucco, retaining wall work)
Subbed Cost $ Subbed Cost % Employee Payroll $ Employee Payroll % None
Mechanical
Subbed Cost $ Subbed Cost % Employee Payroll $ Employee Payroll % None
Plastering
Subbed Cost $ Subbed Cost % Employee Payroll $ Employee Payroll % None
Plumbing – Commercial
Subbed Cost $ Subbed Cost % Employee Payroll $ Employee Payroll % None
Roofing – Commercial
Subbed Cost $ Subbed Cost % Employee Payroll $ Employee Payroll % None
Sewer/Water Mains
Subbed Cost $ Subbed Cost % Employee Payroll $ Employee Payroll % None
Sprinkler Installation (Buildings)
Subbed Cost $ Subbed Cost % Employee Payroll $ Employee Payroll % None
Steel – Structural
Subbed Cost $ Subbed Cost % Employee Payroll $ Employee Payroll % None
Swimming Pool Construction
Subbed Cost $ Subbed Cost % Employee Payroll $ Employee Payroll % None
Wrecking/Demolition
Subbed Cost $ Subbed Cost % Employee Payroll $ Employee Payroll % None
Miscellaneous Classification
Abatement/Asbestos, Lead, Environmental Cleanup
Subbed Cost $ Subbed Cost % Employee Payroll $ Employee Payroll % None
Blasting
Subbed Cost $ Subbed Cost % Employee Payroll $ Employee Payroll % None
Boiler Installation
Subbed Cost $ Subbed Cost % Employee Payroll $ Employee Payroll % None
Caisson or Cofferdam Work/Dam
Subbed Cost $ Subbed Cost % Employee Payroll $ Employee Payroll % None
Drilling
Subbed Cost $ Subbed Cost % Employee Payroll $ Employee Payroll % None
Escalator/Elevator – Install, Maintenance, Repair
Subbed Cost $ Subbed Cost % Employee Payroll $ Employee Payroll % None
Fireproofing
Subbed Cost $ Subbed Cost % Employee Payroll $ Employee Payroll % None
Gas Mains/LPG Work
Subbed Cost $ Subbed Cost % Employee Payroll $ Employee Payroll % None
Gas Pumps
Subbed Cost $ Subbed Cost % Employee Payroll $ Employee Payroll % None
Millwright/Industrial Machinery
Subbed Cost $ Subbed Cost % Employee Payroll $ Employee Payroll % None
Playground Equipment – Maintenance or Repair
Subbed Cost $ Subbed Cost % Employee Payroll $ Employee Payroll % None
Pile Driving
Subbed Cost $ Subbed Cost % Employee Payroll $ Employee Payroll % None
Road, Highway, Bridge, Overpass
Subbed Cost $ Subbed Cost % Employee Payroll $ Employee Payroll % None
Seismic Work/Repair
Subbed Cost $ Subbed Cost % Employee Payroll $ Employee Payroll % None
Seismic Work/Repair Description
Steel – Ornamental
Subbed Cost $ Subbed Cost % Employee Payroll $ Employee Payroll % None
Traffic Signals/Controls
Subbed Cost $ Subbed Cost % Employee Payroll $ Employee Payroll % None
Traffic Signals/Controls Description
Tunneling
Subbed Cost $ Subbed Cost % Employee Payroll $ Employee Payroll % None
Underground Tank Removal/Installation
Subbed Cost $ Subbed Cost % Employee Payroll $ Employee Payroll % None
Waterproofing
Subbed Cost $ Subbed Cost % Employee Payroll $ Employee Payroll % None

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Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime. This application does not bind any of the parties to complete the insurance transaction.
Type Signature (Name and Title)*
Signature*
- I agree to the above, and by checking here, I understand that I am signing this document.
Date*
MM slash DD slash YYYY
Any Umbrella or Excess Liability insurance quote you may receive as a result of your submission of this application is not a contract, binder, or agreement to extend insurance coverage and is not a guarantee that coverage will be extended, or offered. All applications are subject to underwriting approval by the McGowan Companies and to applicable state and federal laws. All policies may not be available in all states. Available limits of liability vary from state to state. Submitting this application does not obligate the McGowan Companies, Integrity Underwriters dba the RWC Insurance Advantage to provide coverage now, or at any time in the future.
Comments
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Step 1 of 9

List the percentage of work you have done or plan to do in the following categories

Subcontractors

Please provide your gross sales for each of the 5 past years and an estimate for the next 12 months:

Describe your three largest projects currently underway or planned for the next year, including values:

Describe your four largest projects over the past five years, including values:

Complete the following table as applicable (DO NOT LEAVE ANY FIELDS BLANK) :

Most Common Classifications

Secondary Classifications

Miscellaneous Classification