Contractor GL App

HCC Contractor Application

Please complete the form below and click the submit button to complete the application.

Fields marked with (*) are required fields.

Producer Information

Agent Name*

Agency Address*

Agent Phone*

Agency Email*

Insured Information

Effective Date*

First Named Insured*

DBA

Form of Business*

Mailing Address*

City*

State*

Zip Code*

Phone Number*

Contractrator License NO.*

Classifications

Enter the Percentage of Work in respective Classifications

Awning Contractor

Boiler and Steam Contractor

Carpentry - Framing

Carpentry - Finish

Concrete Contractor

Debris Removal Contractor

Drilling Contractor - Water

Drywall Contractor

Electrical Contractor

Excavation Contractors

Fencing Contractor

Floor Covering Contractor - Not Tile or Stone

Glazing Contractor (sales based)

HVAC Contractor

Insulation Contractor

Landscaping Services

Lawn Care

Locksmiths (sales based)

Low Voltage Systems Contractor

Masonry Contractor

Metal Erection - Decoractive

Metal Products Contractor

Painting Contractor

Paper Hanging Contractor

Refrigeration Contractor

Renovation / Handyman

Septic Systems Contractor

Sheet Metal Contractor

Sign Contractor

Sign Installation - Non-electrical

Solar Contractor

Swimming Pool Maintenance

Tile and Stone Installation Contractor

Vacuum Systems Contractor

Water Conditioning Contractor

Description of Operations

Describe Operations (minimum 10 words to describe)*

Contact Information

First Name*

Middle Name

Last Name*

SS#*

Address*

City, State & Zip*

Exposure Information

Number of Owners*

Number of Employees*

Employee Payroll*

Subcontracted Costs*

Gross Receipts*

Coverage and Factors

Limits*

Deductible*

Residential Construction Options

New Residential – Condo Work Allowed Yes or No Yes No

Repair & Remodel – Condo Work Allowed Yes No

Commercial Work Only

Limitation of Coverage to Business Description: Include Yes No

Prior Completed or Abandoned Work Exclusion: Include Yes No

Continuous or Progressive Injury and Damage Exclusion: Include Yes No

Absolute Bodily Injury to Employees Exclusion: Include Yes No

Sunset Provision - 3 Year: Include Yes No

General Aggregate Limit Applies per Project: Include Yes No

Coverage Enhancement Package: Included at no additional charge

"Contractors Coverage Enhancement Package" refers to the endorsements which provide a mix of enhanced and additional coverage’s, including:

Primary & Non-Contributory to Other Insurance, Waiver of Subrogation-Blanket, Broad Knowledge of Occurrence, Contractual Liability-Railroads, Contractual Liability for Personal & Advertising Injury, Electronic Data Liability, Expected or Intended Injury, In Rem Actions, Liberalization Clause, Non-Owned Aircraft, Non-Owned Watercraft, Property Damage-Elevators, and Supplementary Payments.

This complimentary package of enhancements is provided to the insured at no additional charge.

*Refer to forms HCS 040 01 and HCS 040 06 for the actual endorsement wording and policy amendments.

Terrorism Coverage: Included at no additional charge

"Terrorism Coverage" refers to coverage provided for acts of terrorism certified by the Secretary of the Treasury in concurrence with the Secretary of State and the Attorney General of the United States in accordance with the federal Terrorism Risk Insurance Act. This coverage is provided to the applicant at no additional charge.
*Refer to form CG 21 70 01 08 Cap On Losses From Certified Acts of Terrorism and form IL 09 85 01 08 Disclosure Pursuant To Terrorism Risk Insurance Act for more details.

Employee Benefits Liability Coverage: Include Yes No

Scheduled AI Endorsement CG 20 37 07 04: Include Yes No

Additional Insured - Owners, Lessees or Contractors - Completed Operations." This endorsement amends Section II of policy to include as an insured the person or organization shown in the Schedule, and provides the coverage included in the products-completed operations hazard. This endorsement is available for no charge.
*Refer to form CG 20 37 07 04 for the actual endorsement wording and policy amendments.

Scheduled AI Endorsement CG 20 10 11 85: Include Yes No

* Cost is $500.00 per A/i

Questions

Does the applicant or applicant's company have knowledge of citations for safety violations by any governmental agency, any pending claims, any anticipated claims which have not yet been reported, or any occurrences, facts, incidents, circumstances, accidents, or damages that a reasonably prudent contractor might expect to give rise to a claim or lawsuit whether valid or not? Yes No

Has or will the applicant lease, loan or rent any equipment to others with or without operators? Yes No

Has the applicant or applicant's company had any claims or losses, regardless of whether or not a loss was reported or covered by insurance, within the last three years? Yes No

If YES, please explain and / or provide loss history:

Has or will the applicant sub-contract work to uninsured contractors? Yes No

Has or will the applicant complete any fire, mold, or water remediation work Yes No

Has or will any of applicant's operations involve blasting operations, demolition work, or the wrecking of any buildings or structures? Yes No

Has or will any of applicant's operations involve hazardous material, asbestos, EIFS, Mold, Chinese Drywall, radon, lead, or any pollution abatement of any kind? Yes No

Has or will applicant's operations involve roofing or any roofing related work such as flashings, roof tear-off, and chimney construction or repair? Yes No

Does applicant own, operate or supervise any premises or operations for which coverage is not being requested? Yes No

Has or will the applicant perform work involving hospitals, airports, railroads, or bridges? Yes No

Has or will any of applicant's operations involve tunneling or underground/below grade work? Yes No

Has or will the applicant perform any work other than work as a Painting Contractor? Yes No

Has or will the applicant perform any painting of steel structures or bridges? Yes No

Has or will the applicant perform any sandblasting? Yes No

Has or will the applicant perform any waterproofing operations? Yes No

Has or will the applicant perform any work on buildings or structures exceeding three (3) stories in height? Yes No

Has or will the applicant perform any roof painting? Yes No

Has or will the applicant perform any painting of tanks? Yes No

Has or will the applicant perform any work on streets, roads or highways? Yes No

Has or will the applicant perform any work including paper or vinyl goods, cork, burlap, or carpet-type wall coverings? Yes No

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HCC Contractor Application - (Complete)

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