1. PRODUCER NAME:

Ritchie & Rose Insurance Services, Inc.          

2. PRODUCER ADDRESS:

PO Box 1114, Anderson, California 96007          

3. PRODUCER TELEPHONE:

530-365-4705

4. PRODUCER CONTACT NAME

    Sheri Ritchie              

5. PRODUCER FAX

866-885-1428

6. PRODUCER E-MAIL

sheriR@ritchieandrose.com         

7. APPLICANT NAME

INDIVIDUAL

PARTNERSHIP

CORPORATION

JOINT VENTURE

LLC

OTHER

8.  APPLICANT   STREET ADDRESS

9.  CITY

10. STATE

11. ZIP

12.  APPLICANT   MAILING ADDRESS

13. CITY

14. STATE

15. ZIP

16. PHONE NUMBER

17. INSPECTION CONTACT NAME:

18.  YEARS IN BUSINESS UNDER CURRENT NAME

       YEARS

19. TOTAL YEARS EXPERIENCE AS A CONTRACTOR

      YEARS

20. CONTRACTOR LICENSE NUMBER (S)

21. LICENSED STATE (S)

22. TAX ID NUMBER

23. PROPOSED POLICY EFFECTIVE DATE

24. REQUESTED PER OCCUR. LIMIT

25. REQUESTED AGGREGATE LIMIT

26. REQUESTED PER CLAIM DEDUCTIBLE

27. DESCRIPTION OF YOUR OPERATIONS

EXPLAIN ALL "YES" RESPONSES IN REMARKS

28. HAVE YOU PERFORMED IN THE PREVIOUS THREE (3) YEARS, OR PLAN TO PERFORM IN THE NEXT YEAR, ANY OF THE FOLLOWING:

YES

NO

YES

NO

YES

NO

YES

NO

A. AIRPORT WORK

F. DAMS, LEVEES OR BRIDGES

K. OIL LEASE WORK

O. TOWNHOUSES

B. ASBESTOS ABATEMENT

G. DEMOLITION XS 3 STORIES

L. RAILROADS

P. TRAFFIC SIGNALS

C. BLASTING OPERATIONS

H. EARTHQUAKE RETROFIT

M. SCAFFOLDING  ERECTION

Q. TUNNELING

D. CHEMICAL SPRAYING

I. EMPLOYEE LEASING

N. SWIMMING POOLS

R. WRAP UPS OR OCIPS

E. CONDOMINIUMS 

J. EXTERMINATION

REMARKS:             

NEXT 12 MONTHS - TYPE OF WORK PERFORMED:

29. PERCENTAGE OF WORK PERFORMED = 100%

RESIDENTIAL

       %

COMMERCIAL

30. PERCENTAGE OF WORK PERFORMED = 100%

GENERAL CONTRACTOR

      %

SUBCONTRACTOR

           %

31. PERCENTAGE OF WORK PERFORMED = 100%

NEW CONSTRUCTION

     %

OTHER

           %

NEXT 12 MONTHS - TYPE OF BUILDINGS  TO BE BUILT OR WORKED ON:

32. IN THE NEXT 12 MONTHS, HOW MANY BUILDINGS WILL YOU WORK ON IN THE FOLLOWING CATEGORIES: 

 CUSTOM HOMES

#:

 TRACT HOMES - 2 TO 10 TRACTS

#:

 TRACT HOMES – 11TO 50 TRACTS 

#:

TRACT HOMES IN TRACTS OVER 50

#:

33. IN THE NEXT 12 MONTHS, HOW MANY BUILDINGS WILL YOU WORK ON IN THE FOLLOWING CATEGORIES: 

APART-MENTS

#:

CONDO-MINUMS

#:

TOWN-HOMES OR ROW HOMES

#:

  COMMER-CIAL BUILDINGS

#:

FINANCIAL INFORMATION:

PERIOD

34. YEAR

35. # OF PROJECTS

COMPLETED

36. # OF PROJECTS

WORKED ON

37. GROSS

RECEIPTS

38. SUBCONTRACTING

COSTS

39. GROSS PAYROLL

A. NEXT 12 MONTHS

$          

$          

$          

B. CURRENT  YEAR

$     

$          

$          

C. 1^st PRIOR YEAR

$          

$          

$              

D. 2^nd PRIOR YEAR

$     

$     

$     

PRIOR INSURANCE COMPANY INFORMATION:

PERIOD

40. POLICY PERIOD

41. INSURANCE

COMPANY

42. POLICY

NUMBER

43. POLICY

PREMIUM 

44. POLICY RATE

45. POLICY

LIMIT

46. POLICY

DED.

A. CURRENT YEAR

$          

$          

$          

$          

B. 1^ST PRIOR YEAR

$          

$          

$          

$          

C. 2^ND PRIOR YR.

$          

$          

$          

$          

 EXPLAIN ALL “YES” RESPONSES IN REMARKS – NEXT PAGE (FOR PAST, PRESENT OR PLANNED FUTURE OPERATIONS):

#

QUESTIONS

YES

NO

#

QUESTIONS

YES

NO

47.

DOES APPLICANT LEASE EQUIPMENT TO OTHERS?

48.

HAS APPLICANT ALLOWED OR WILL YOU ALLOW YOUR LICENSE TO BE USED BY ANY OTHER CONTRACTOR?

49.

DOES APPLICANT HAVE ANY OPERATIONS OTHER THAN CONTRACTING?

50.

HAS APPLICANT EVER BEEN ADJUDGED BANKRUPT OR INSOLVENT?

51.

HAS THE APPLICANT EVER BEEN REFUSED A PERFORMANCE BOND OR HAD LIABILITY INSURANCE CANCELLED.

52.

HAS APPLICANT WORKED OR WILL YOU OR YOUR EMPLOYEES WORK UNDER THE USL&H ACT OR THE JONES ACT (MARITIME WORK)?

53.

DOES APPLICANT ALWAYS CHECK WITH LOCAL UTILITIES AUTHORITY BEFORE DIGGING?

54.

DOES THE APPLICANT CARRY WORKERS COMPENSATION ON ALL OF ITS EMPLOYEES?

REMARKS (ATTACH SHEET (S) IF NECESSARY)             

#

QUESTION

ANSWER

#

QUESTION

ANSWER

55.

HOW MANY BUILDINGS WILL APPLICANT BUILD AS A GENERAL CONTRACTOR IN THE NEXT YEAR?

56.

WHAT IS THE MAXIMUM NUMBER OF STORIES OF A STRUCTURE THE APPLICANT WILL WORK ON IN THE NEXT YEAR?

57.

WHAT IS THE GREATEST NUMBER OF BUILDINGS THE APPLICANT HAS BUILT AS A GENERAL CONTRACTOR IN ANY ONE YEAR (LAST 3 YEARS)?

58.

STATES IN WHICH THE APPLICANT HAS OR WILL PERFORM CONTRACTING WORK (LAST 3 YEARS AND NEXT YEAR).

59. PROJECT NAME

60. PROJECT TYPE

61. NATURE OF WORK

62. GROSS RECEIPTS

A

$          

B

$          

C

$          

PLEASE LIST THREE LARGEST PROJECTS THAT YOU ARE CURRENTLY WORKING ON OR WILL COMMENCE IN THE NEXT 12 MONTHS:

63. PROJECT NAME

64. PROJECT TYPE

65. NATURE OF WORK

 66. GROSS RECEIPTS

A

$          

B

$          

C

$          

#

QUESTIONS

YES

NO

67.

DOES APPLICANT HAVE A WRITTEN CONTRACT WITH ITS SUBCONTRACTORS WHICH INCLUDES A HOLD HARMLESS AGREEMENT RELATIVE TO WORK PERFORMED BY THE SUBCONTRACTOR?

68.

ARE YOU NAMED AS AN ADDITIONAL INSURED ON YOUR SUBCONTRACTORS' POLICIES?

69.

DOES APPLICANT HOLD OTHERS HARMLESS AND/OR ARE YOU REQUIRED TO PROVIDE ADDITIONAL INSURED ENDORSEMENTS FOR OTHERS?

70.

ARE YOUR SUBCONTRACTORS REQUIRED TO PROVIDE YOU WITH A CERTIFICATE OF INSURANCE BEFORE COMMENCING WORK?

71.

DOES APPLICANT REQUIRE SUBCONTRACTORS WHO DO WORK FOR THE APPLICANT TO MAINTAIN LIMITS OF LIABILITY OF AT LEAST $1,000,000 PER OCCURRENCE?

LOSS AND CLAIM INFORMATION (5 YEARS):

PERIOD

72. YEAR

73. TOTAL

LOSSES

74. # OF

CLAIMS

75. LARGEST

LOSS

76. CAUSE OF LARGEST LOSS

A. CURRENT YEAR

$          

$          

B. 1^ST PRIOR YEAR

$          

$     

C. 2^ND PRIOR YEAR

$          

$          

D. 3^RD PRIOR YEAR

$          

$          

ARE YOU AWARE OF ANY FACTS, CIRCUMSTANCES, INCIDENTS, SITUATIONS, DAMAGES OR ACCIDENTS THAT MAY GIVE RISE TO A CLAIM OR LAWSUIT (WHETHER VALID OR NOT OR WHETHER COVERED BY INSURANCE OR NOT)?  – ANSWER YES OR NO:   Yes           No          _{IF YES PLEASE COMPLETE THE FOLLOWING:}

77. PROJECT NAME

78. PROJECT TYPE

79. NATURE OF YOUR WORK

80. CLAIMED DAMAGES

A

$          

B

$          

C

$          

D

$          

E

$          

#

QUESTIONS

YES

NO

81.

HAS ANY LOCAL, STATE OR FEDERAL GOVERNMENT AGENCY OR LICENSING BOARD CITED YOU FOR VIOLATION OF ANY LAW OR REGULATION OR INVESTIGATED YOU IN THE PAST FIVE YEARS?

82.

WITHIN THE LAST FIVE YEARS HAVE YOU BEEN NAMED IN LITIGATION REGARDING FAULTY CONSTRUCTION?

83.

WITHIN THE LAST FIVE YEARS, HAS ANY PERSON OR ENTITY DEMANDED THAT YOU DEFEND THEM, OR HOLD THEM HARMLESS, IN ANY CLAIM OR LAWSUIT?

84.

WITHIN THE LAST FIVE YEARS HAS ANY LAWSUIT BEEN FILED, OR CLAIM OTHERWISE BEEN MADE, AGAINST YOU OR YOUR COMPANY OR ANY PARTNERSHIP OR JOINT VENTURE OF WHICH YOU HAVE BEEN A MEMBER, OR YOUR COMPANY'S PREDECESSORS IN BUSINESS, OR AGAINST ANY PERSON, COMPANY OR ENTITIES ON WHOSE BEHALF YOUR COMPANY HAS ASSUMED LIABILITY?  FOR THE PURPOSES OF THIS APPLICATION ONLY, A CLAIM OR LAWSUIT MEANS A RECEIPT OF A DEMAND FOR MONEY, SERVICES, ARBITRATION OR MEDIATION.

IF APPLICANT ANSWERED QUESTIONS 81, 82, 83 OR 84 WITH A YES, PLEASE PROVIDE THE FOLLOWING INFORMATION FOR EACH CLAIM AND OR LAWSUIT:

85. PROJECT NAME

86. PROJECT TYPE

87. NATURE OF YOUR WORK

88. CLAIMED DAMAGES

A

$          

B

$          

C

$          

D

$          

E

$          

REMARKS:            

89.

BLANKET ADDITIONAL INSURANCE COVERAGE

YES

NO

90.

BLANKET WAIVER OF SUBROGATION

YES

NO

91.

SUNSET CLAUSE LIMITATION

YES

NO

92.

PREMIUM FINANCING

YES

NO

93.

LIST SPECIFIC ADDITIONAL INSUREDS IF BLANKET IS NOT SELECTED

NAME

ADDRESS

 FORMDROPDOWN

 FORMDROPDOWN

 FORMDROPDOWN

 FORMDROPDOWN

 FORMDROPDOWN

 FORMDROPDOWN

Signature of Applicant:                      

Date:                                                     

Title (Officer, Partner or Owner)