General Liability Policy Certificate Insurance for Small Business

Document Sample
General Liability Policy Certificate Insurance for Small Business Powered By Docstoc
					                                                            STATEWIDE INSURANCE CORP.
                                                              P.O. Box 30527, Phoenix, Arizona 85046

                                                      ARIZONA, NEVADA, NEW MEXICO & UTAH
                                                           Artisan Contractor's Program
                                                       CERTAIN UNDERWRITERS AT LLOYD'S

Insured:                                                                                     Policy #:
Effective:                                                                                   Agency:
State:                                                                  Please Select Risk State

Has this insured had insurance coverage during the prior 12 months?
Is this business a New Venture?
Has this insured been claim free with Statewide for more than one year?
                                                                                                                 PREMIUM MODIFIER =               1.00


Rates effective 12/10/07
                                                         GENERAL LIABILITY CALCULATIONS

                                                      Please Select Class Description Above
Class Description and Code #:
Occurrence Limit:                                                       Please Select Desired Occurrence Limit
Do you want Double Aggregate Limits?
General Aggregate Selected
Deductible ($500/$1,000)                                                Please Select Deductible
Additional Insured's Requested ($75 each):


                                       Incr. Limits      Deductible           Double Agg.                            Final                        Final
    Class Code             Base Rate                                                             Modifier                           Payroll
                                         Factor            Factor               Factor                               Rate                       Premium




          0                   0
          0                   0                              TOTAL GL PREMIUM                       $0
          0                   0
          0                   0                             TERRORISM PREMIUM                       $0             Rejected
          0                   0
          0                   0                                 Accept Terrorism?                                Submit Signed Terrorism Form
          0                   0

                                                                      FINAL COMPUTATIONS

                                                      General Liability:                            $0
                                                      Add'l Insureds:                               $0
                                                          Sub-Total                                 $0
                                                      Policy Fee                                    $0
                                                      Terrorism:              Rejected              $0
                                                                                                                              Print Worksheet, then
                                                      Taxes / Fees:                          Select Risk State
                                                                                                                              Proceed to Page 2 for
                                                      Filing Fee (NV only):                       $0.00                             Application

                                                           Total                            See Note Below


                                                      Premium Not Offered; Please Select Deductible
                                                                                                                                                   P.O. Box 30527
                                                                                                                                           Phoenix, Arizona 85046
                                                                                                                                (602) 494-6900 (800) 228-1710
                                                                                                                                              Fax (602) 494-6999


MARKET AREA: ARIZONA, NEVADA, NEW MEXICO, UTAH

                                                       ARTISAN CONTRACTOR'S PROGRAM
This program is designed for artisan's or contractor's businesses having gross receipts less than $750,000. It is specifically
geared to be competitive, flexible and easy to rate for small to medium sized subcontractors. Rates subject to change without notice.
                              Applicant's Name:                                                             Producer's Name:




Address:                                                                        Address:

City,State,Zip:                                                                 City,State,Zip:

Phone:                                    Cell Phone:                           Phone:                                   Fax:

Location Address (if different from mailing):

Requested Effect. Date (m/dd/yy):         From:                                               To:

Applicant is? (Select One)

Applicant's Business:                                                                                      How Long in business?


                                                         PREVIOUS CARRIER INFORMATION
Previous Carriers (Past 3 Years)                                                Has any company ever canceled or refused renewal?

     1.

     2.

     3.


                                                                   PREVIOUS LOSSES
                    PRESENT YEAR                                          LAST YEAR                                        SECOND PRIOR YEAR
      Type of Loss                   Amount Paid           Type of Loss               Amount Paid                Type of Loss                 Amount Paid




                                                             LIABILITY UNDERWRITING
Risks with more than 25% of subcontracted work performed are not eligible.
Additional named insureds may be added to the policy for $75.00 each, fully earned. Charge is additional to minimum premium.
The deductible is $500 ($1,000 for classes shown with **) bodily injury, property damage, loss adjustment and expense.
All policies are subject to a 25% minimum earned premium or $100 minimum earned premium, whichever is greater.
All policies are subject to audit.
Minimum policy premium is $675.00
Each policy will have a $150.00 inspection fee.
Premiums are based on $20,000 payroll for each owner, partner or officer. Charge for employees is based on their actual payroll.
New ventures - add 15% surcharge
No insurance for the last 90 days, add 15% surcharge.


                                                                          SUBMIT
1. Risks Where Limits of Liability Exceed $1 Million                            6. Insureds with Leased Employees
2. More Than 10 Employees                                                       7. Risks Having 2 or More Losses in the Past 3 Years
3. Multiple Classifications                                                     8. Risks Having Paid or Reserved Claims of $5,000 or Higher
4. Any Deviation to the Program                                                 9. Risks with Gross Receipts in Excess of $750,000 Annually
5. Any Work on Hillsides, Slopes or Landfills                                   10. Work on Any Buildings Over 3 Stories
                                                          General Contractors or Project Managers




           60785224-01c0-426c-b257-14ea7b5aada6.xls                                                                                Vers. 10/06 - Rev 2/08
                                                                          PROHIBITED
1. Any Work Performed on New Subdivisions or Tract Housing                     6. Builders of Entire Structures or Those Who Purchase Property
2. Any Work Performed on New Apartments or Condominiums                          to Renovate for Sale
3. Any Blasting Work                                                           7. Any Professional Liability, Architect or Engineer
4. Pressure Tanks or Vessels - LPG Work                                        8. Oil Field Work of Any Kind - Landfills
5. Soil Testing                                                                9. Asbestos Removal or Lead Paint Removal



                                                      COVERAGES OFFERED UNDER THIS PROGRAM
1. Commercial General Liability                                                4. Medical Payments - $1,000
2. Products / Completed Operations                                             5. Fire Legal - $50,000
3. Personal Injury and Advertising Injury                                      6. Additional Interests



                                      GENERAL INFORMATION (ALL QUESTIONS MUST BE ANSWERED)
1. Description of Operations:

2. Is the applicant a subsidiary of another entity?

3. Does the applicant own any subsidiaries?

4. Any exposure to flammables, explosives or hazardous chemicals?

5. Does the applicant use sub-contractors?

6. If yes, are Certificates of insurance required from sub-contractors?

7. Do any Operations include excavation or earth moving?

8. Have there been any losses in the last three years?

9. Any demolition of buildings or structures of any kind?

10. Any work performed outside the State in the last 3 yrs.?



                                                             LIABILITY LIMITS REQUESTED
                             Liability Limit Requested:

                    Do you want Double General Aggregate?

                                Deductible Requested:



                                                                ADDITIONAL INSURED #1
Name:

Address:                                                                              Additional Insured or Cert Holder Only?

City,State,Zip:

Interest of Additional Insured:


                                                                ADDITIONAL INSURED #2
Name:

Address:                                                                              Additional Insured or Cert Holder Only?

City,State,Zip:

Interest of Additional Insured:



NO COVERAGE WILL BE BOUND UNLESS THE APPLICATION IS SIGNED BY BOTH THE PRODUCER AND THE INSURED
                 AND IS ACCOMPANIED BY THE COMPLETED, SIGNED TERRORISM OFFER.


Signature of Producer                                                                                         Date:


Signature of Applicant                                                                                        Date:




           60785224-01c0-426c-b257-14ea7b5aada6.xls                                                                              Vers. 10/06 - Rev 2/08
                                                            POLICYHOLDER DISCLOSURE
                                                               OFFER OF TERRORISM
                                                              INSURANCE COVERAGE


You are hereby notified that under the Terrorism Risk Insurance Act of 2002, effective November 26, 2002, that you now have a right to purchase insurance
coverage for losses arising out of acts of terrorism, as defined in Section 102(1) of the Act : The term “act of terrorism” means any act that is certified by the
Secretary of the Treasury, in concurrence with the Secretary of State, and the Attorney General of the United States—to be an act of terrorism; to be a violent
act or an act that is dangerous to human life, property; or infrastructure; to have resulted in damage within the United States, or outside the United States in the
case of an air carrier or vessel or the premises of a United States mission; and to have been committed by an individual or individuals acting on behalf of any
foreign person or foreign interest, as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the
United States Government by coercion.


YOU SHOULD KNOW THAT COVERAGE PROVIDED BY THIS POLICY FOR LOSSES CAUSED BY CERTIFIED ACTS OF TERRORISM IS PARTIALLY
REIMBURSED BY THE UNITED STATES UNDER A FORMULA ESTABLISHED BY FEDERAL LAW. UNDER THIS FORMULA, THE UNITED STATES PAYS
90% OF COVERED TERRORISM LOSSES EXCEEDING THE STATUTORILY ESTABLISHED DEDUCTIBLE PAID BY THE INSURANCE COMPANY
PROVIDING THE COVERAGE. THE PREMIUM CHARGED FOR THIS COVERAGE IS PROVIDED BELOW AND DOES NOT INCLUDE ANY CHARGES
FOR THE PORTION OF LOSS COVERED BY THE FEDERAL GOVERNMENT UNDER THE ACT.


THERE IS A CAP ON OUR LIABILITY TO PAY FOR SUCH LOSSES IF THE AGGREGATE AMOUNT OF INSURED LOSSES UNDER THE TERRORISM
RISK INSURANCE ACT OF 2002 EXCEEDS $ 100,000,000,000 DURING THE APPLICABLE PERIOD FOR ALL INSUREDS AND ALL INSURERS
COMBINED. IN THAT CASE, WE WILL NOT BE LIABLE FOR THE PAYMENT OF ANY AMOUNT WHICH EXCEEDS THAT AGGREGATE AMOUNT OF
$100,000,000,000.

U.S. TERRORISM RISK INSURANCE ACT PREMIUM


THE CHARGE FOR INCLUDING COVERAGE FOR LOSSES CAUSED BY CERTIFIED ACTS OF TERRORISM IN YOUR INSURANCE COVERAGE IS
$__________. THIS CHARGE IS SEPARATE AND IN ADDITION TO THE PREMIUM CHARGED IN RESPECT OF ALL OTHER PERILS COVERED BY THE
POLICY.


THE ABOVE QUOTATION HAS BEEN ISSUED IN ACCORDANCE WITH THE REQUIREMENTS OF THE U.S. TERRORISM RISK INSURANCE ACT OF 2002 AND
ONLY RELATES TO “act of terrorism” AS DEFINED UNDER SAID ACT. THE TERRORISM EXCLUSION THAT IS APPLICABLE TO THE PLACEMENT
REFERENCED ABOVE STILL APPLIES IN FULL FORCE AND EFFECT TO ANY ACTS OR EVENTS THAT ARE NOT INCLUDED IN SAID DEFENITION OF “act of
terrorism”. FURTHERMORE, IT IS EXPLICITLY UNDERSTOOD AND AGREED THAT THIS QUOTATION IS OFFERED IN CONJUNCTION WITH ALL TERMS,
CONDITIONS AND EXCLUSIONS OF THE QUOTED PLACEMENT REFERENCED ABOVE AND DOES NOT CONSTITUTE AN OFFER TO PROVIDE STAND-
ALONE TERRORISM INSURANCE.


PRIOR TO THE BINDING OF COVERAGE FOR YOUR POLICY OR POLICIES, PLEASE INFORM YOUR AGENT OR BROKER IF YOU WOULD LIKE TO
PURCHASE COVERAGE FOR CERTIFIED ACTS OF TERRORISM


                     I hereby elect to purchase Terrorism coverage for a prospective premium of $
                     I hereby elect to have the exclusion for terrorism coverage reinstated. I understand that I will have no
                     coverage for losses arising from acts of terrorism that were previously excluded.


                                                                                    Certain Underwriters at Lloyd's, London
   Policyholder / Applicant's Signature                                                        Name of Insurer


                      Print Name                                                                    Contract Reference


                           Date                                                               Certificate / Policy Number
                                             Nevada Surplus Lines Association
                                                DECLINATION DETAIL

This form is to be used when the policy provides insurance for coverage that cannot be written with admitted insurers.
(Category is not listed on open lines eligible for export.) In pursuant of 685A.215 of NRS, identify three admitted
insurers marketing the class of insurance that declined the risk. Include with this submission form NSLA101.


NAME OF INSURED:


POLICY NUMBER:



                                                             1.
Admitted Insurer:
Address:
Phone Number:                                                     Underwriter
Reason for Declination (enter code from bottom):



                                                             2.
Admitted Insurer:
Address:
Phone Number:                                                     Underwriter
Reason for Declination (enter code from bottom):



                                                             3.
Admitted Insurer:
Address:
Phone Number:                                                     Underwriter
Reason for Declination (enter code from bottom):


                                               Reason for Declination Codes

                1.   Unacceptable Class of Business                             5.   No Market
                2.   Age of Building                                            6.   No Prior Insurance
                3.   Declined to Quote                                          7.   Excessive Claims
                4.   Doesn't Fit Underwriting Requirement                       8.   Other (Please Explain)




SLA AFFIRMATION:                                I hold a Surplus Lines license and will do the SLA filings.
                                                Please do the SLA filings for me. (Must send this form!)




BROKER/AGENT NAME                                              SIGNATURE                                           DATE
                                     EVIDENCE OF GOOD FAITH EFFORT TO PLACE

                                             The Surplus Line Association of Utah

     This form is to be used to document the efforts made by the suplus lines broker (and/or producing agent) to place
     insurance coverage concerned with an admitted insurer before approaching the suplus lines insurer.

     Policy No.                                               Name of Insured:

     List the admitted insurers contacted.

                NAME OF INSURER                              NAME OF UNDERWRITER                        PHONE NUMBER
1.
     Reason for Declining:



2.
     Reason for Declining:



3.
     Reason for Declining:




     If any additional insureds were contracted, attach an additional list.

     Provide any further explanation about the insured and your effort to place the insurance with an admitted insurer
     which would help support the need to place the policy with a surplus lines insurer. Explain why you consider this
     to be reasonable evidence of a good faith effort to place the coverage with an admitted insurer.
     Attach additional sheets if necessary.




     SLA AFFIRMATION:                             I hold a Surplus Lines license and will do the SLA filings.
                                                  Please do the SLA filings for me. (Must send this form!)




     Signature of Producing Producer                                Signature of Surplus Lines Broker

				
DOCUMENT INFO
Description: General Liability Policy Certificate Insurance for Small Business document sample