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AmTrust International Underwriters Ltd

1
Wesco Insurance Company
Security National Insurance Company

Contractors
General Liability
Application

Agency Information
Agency Business Name: _________________________________________________________________.
Agency Contact First & Last: _____________________________________________________________.
Agency Contact Number: ________________________________________________________________.
Agency Email Address: _________________________________________________________________.
Agency Mailing Address: ________________________________________________________________.
Applicant Information
Applicant Business Name: _______________________________________________________________.
Applicant Owner(s) First & Last Name: _____________________________________________________.
Applicant Phone Number: ________________________________________________________________.
Applicant E-mail Address: _______________________________________________________________.
Applicant Mailing Address: ______________________________________________________________.
Applicant Business Address: ______________________________________________________________.
Applicant License Number (or pending): ____________________________________________________.
Applicant Entity Business Type: [_] Sole Proprietor or Individual
[_] Partnership
[_] Trust
[_] Limited Partnership
[_] Corporation
[_] Joint Venture
[_] LLC
[_] LLP
General Liability Rating Criteria
Limit of Insurance: [_] $300,000/$300,000/$300,000
[_] $500,000/$1,000,000/$1,000,000
[_] $1,000,000/$2,000,000/$1,000,000
Deductible: [X] $500

[_] $500,000/$500,000/$500,000
[_] $1,000,000/$1,000,000/$1,000,000
[_] $1,000,000/$2,000,000/$2,000,000

Estimated Yearly Owner Payroll for this policy:
Estimated Yearly Employee Payroll for this policy:
Estimated Yearly Subcontracting Costs for this policy:
Estimated Yearly Gross Receipts for the year:
Total Number of Owners for this policy:
Total Number of Part Time Non-Clerical Employees for this policy:
Total Number of Full Time Non-Clerical Employees for this policy:

[$_________________]
[$_________________]
[$_________________]
[$_________________]
[#___________]
[#___________]
[#___________]

Classification: (Must equal 100% and limited to 4 Contractor Trades per policy)
Contractor Trade #1: ______________________________________________________.
Contractor Trade #2: ______________________________________________________.
Contractor Trade #3: ______________________________________________________.
Contractor Trade #4: ______________________________________________________.

[__________%]
[__________%]
[__________%]
[__________%]

Business Experience / Insurance History:
[_] New In Business
[_] Operating Business Without Prior Insurance
[_] 1-59 days without GL coverage
[_] 60+ days lapse in GL coverage
[_] 1 Year in business with no lapse in GL coverage and no losses
[_] 2 Years in business with no lapse in GL coverage and no losses
[_] 3 Years in business with no lapse in GL coverage and no losses
[_] 4 Years (or more) in business with no lapse in GL coverage and no losses
[_] Other - claim in the past year
Total Number Of Years In Business:
Total Number Of Years Of Experience:

[#___________]
[#___________]

1

2
Prior General Liability Carrier Information: (In order to ensure that proper credits/debits are applied to
this account, prior carrier information must be provided).
No
Policy
Insurance
Insurance
Policy # or
Term
Coverage
Company Name
MGA/Wholesaler
Premium
Current Term
[_]
$
Prior Term #1
[_]
$
Prior Term #2
[_]
$
Prior Term #3
[_]
$
Prior Term #4
[_]
$
Claims History: (Description of Losses or No Claims or Losses)
Policy
Number
Term
of Claims
Total Amount of Losses
Current Term
$
Prior Term #1
$
Prior Term #2
$
Prior Term #3
$
Prior Term #4
$

No
Claims or Losses
[_]
[_]
[_]
[_]
[_]

Business Operations: (Questions 1 - 4)
1. What percentage of your work is (each column must add to 100%)
Structure
Type
Residential
Industrial
Commercial

Percentage
of Work
%
%
%

Construction
Type
New Construction
Structural remodel/additions
Service and Repair
Non-structural Remodel

Percentage
of Work
%
%
%
%

2. Gross Receipts for the next 12 months and last 3 years:
Next 12 Months
Last 12 Months
2nd Year Prior
3nd Year Prior

$
$
$
$

Not Applicable
Not Applicable
Not Applicable

3. Please list your largest current/planned job and your largest job in the past 3 years:
2

Description of Largest Current/Planned Job
Value of job

$

Description of Largest Job In Last 3 Years:
Value of job
$
Not Applicable
4. Description Of Operations: (must be at least 10 words)

2

3
Optional General Liability Coverages:

X

-Up to 25% Credit -- no work on New Residential Structures prior to the certificate of occupancy (remodel work ok)
-Per Project Aggregate: $250 (fully earned)
-Employee Benefits Liability: $250 (Fully earned)
-Remove Subsidence Exclusion Endorsement.
-Scheduled Additional Insured Endorsement (CG2010 11/85 equivalent) - only allowed on commercial projects: $500
-Limitation of Coverage to Business Description Endorsement.
-Remove Employer's Liability Exclusion (Action Over) Endorsement.
-Faulty Workmanship Coverage (Contractors Errors and Omissions) (Premium is fully earned)
-Contractors Miscellaneous Tools and Small Equipment Coverage. Miscellaneous Tools and Small Equipment (Valued under
$1,500) only available in our Victory Admitted and Victory Non-Admitted programs.
-Multi-policy Credit - Does the insured have an existing policy underwritten by AmTrust North America including its
affiliates? *if yes provide the policy number.

Policy #

Common Eligibility Questions: (Yes or No)

Yes No

Is the applicant currently performing any work involving new residential properties prior to the certificate of occupancy or
does the applicant plan to in the future?
Does the applicant have at least 2 years of construction experience in the field of their current business/trade?
Are annual gross receipts over $1,500,000 in any of the past 2 years?
In the past three (3) years, has the applicant worked on a job where the applicant’s contract value (including changes) was
greater than $750,000? Note: Prior Work Buy Back is not available for applicants with prior jobs over $750,000.
Has the applicant has more than two losses or more than $20,000 total paid for losses in the past 4 years?
Does the applicant require all subcontractors (if used) to name their company as an additional insured AND does the
insured require and maintain proof of general liability and workers compensation insurance of subcontractors?
Has the applicant completed any work involving, related to, or about the premises of APARTMENT CONVERSIONS (to
condominiums/townhomes/timeshares) or Construction work involving CONDOMINIUMS, TOWN HOMES OR TIME
SHARES in the past 10 years or does the applicant plan to in the future?
In the past 4 years has the applicant performed or completed or is the applicant currently performing any work, prior to the
certificate of occupancy, involving, related to, or about the premises of New Homes in TRACTS OR SUBDIVISIONS OF
MORE THAN TEN (10) HOMES (including all phases) or are there plans to do so in the future?
In the past 2 years has the applicant built or is the applicant currently building any structures as a GENERAL
CONTRACTOR (ground up construction) or DEVELOPER, or performed work as a CONSTRUCTION MANAGER or
PROJECT MANAGER or are there plans to do so in the next year?
Does work covered under "wrap-up" or OCIP policies comprise more than 15% of the applicant’s current / planned jobs?
In the past 5 years has the applicant performed any repair or remediation of fire damage, water damage, mold damage or
termite damage as the General Contractor or are there plans to do so in the next year?
Has the applicant performed work related to: railroads, gas stations, refineries, chemical plants, airports, public utilities,
hospitals, nursing homes, senior housing, military housing or student dormitories or plan to in the future?
Does the applicant own vacant land, real estate development property or model homes?
Has the applicant had any bankruptcies or tax or credit liens within the last 5 years?
Has any policy being applied for been declined/non-renewed, or cancelled for non-payment within the last 3 years?
Have there been losses, claims or “legal actions” (lawsuits, mediations, arbitrations) against the applicant in the past 4
years or are there any pending against them now? If yes, please provide detailed description.
Has the applicant had any construction defect claims and/or ”legal actions” (lawsuits, mediations, arbitrations)?
Does the applicant do any work outside of the state he/she is domiciled in?
Is the applicant a subsidiary of affiliate of another entity or does the applicant have any subsidiaries or affiliates?
In the past 4 years, has the applicant performed or completed or is the applicant currently performing any work involving,
related to or about the premises of NEW MOBILE HOME PARKS CONTAINING MORE THAN TEN SPACES
(Including all phases) or are there plans to do so in the future?

The Answer is No to All
Trade Specific Class Code Eligibility:
91111 - Air Conditioning
No work involving refrigeration systems other than cooling of air. No work on LPG gas lines or pumps. No crane work performed by
the applicant. No work on automobiles or RV's. No solar energy panel work. No work on fireplaces, wood stoves or pellet stoves.
91150 - Appliance Installation - Commercial
No work on LPG gas lines or pumps. No rental of equipment to others. No work on automobiles or RV's. No fire suppression or alarm
work. No underground tank work. No sales of items not installed by the applicant.
91155 - Appliance Installation - Household (residential)
No work on LPG gas lines or pumps. No rental of equipment to others. No solar energy panel work. No work on automobiles or RV's.
No fire suppression or alarm work. No sales of items not installed by the applicant.

3

4
91342 - Carpentry - Commercial
No residential framing as a subcontractor. No structural work over 3 stories. No hillside construction (slopes greater than 20 degrees).
No solar energy panel work. No roofing performed by the applicant. No work on LPG gas lines or pumps. No environmental clean up.
No playground equipment/bleacher work. No waterproofing. No fire suppression or alarm work. No rental of equipment to others. No
demolition (structural) of residences or commercial buildings. No underpinning or shoring. No retaining walls greater than 6 feet tall.
No work more than 12 feet below grade. No foundation work or repairs. No seismic retrofitting other than shear walls or foundation
bolting or does work constituting more than 20% of total operations. No EIFS work. No window installation or Repair not done in
conjunction with an overall remodeling job. No fabrication or manufacturing of items not installed by the applicant.
91344 - Carpentry - Handyman
-No work on jobs that are over $2,500 (or $500 without a license) in total value. No residential framing as a subcontractor. No solar
energy panel energy panel work. No roofing performed by the applicant. No work on LPG gas lines or pumps. No environmental
clean up. No waterproofing. No fire suppression or alarm work. No rental of equipment to others. No foundation repairs. No
playground equipment/bleacher work. No window installation or repair. No power washing or sand blasting. No fabrication or
manufacturing of items not installed by the applicant.
92338 - Carpentry Interior
-No residential framing as a subcontractor. No solar energy panel work. No rental of equipment to others. No demolition (structural)
of a residence or commercial building. No foundation work or repairs. No seismic retrofitting other than shear walls or foundation
bolting or does work constituting more than 20% of total operations. No EIFS work. No window installation or repair not done in
conjunction with an overall remodeling job. No fabrication or manufacturing of items not installed by the applicant.
91340 - Carpentry - Residential
-No residential framing as a subcontractor. No structural work over 3 stories. No hillside construction (slopes greater than 20 degrees).
No solar energy panel work. No roofing performed by the applicant. No work on LPG gas lines or pumps. No environmental clean up.
No playground equipment/bleacher work. No waterproofing. No fire suppression or alarm work. No rental of equipment to others. No
demolition (structural) of a residence or commercial building. No underpinning or shoring. No retaining walls greater than 6 feet tall.
No work 12 feet below grade. No foundation work or repairs. No seismic retrofitting other than shear walls or foundation bolting or
does work constituting more than 20% of total operations. No EIFS work. No window installation or repair not done in conjunction
with an overall remodeling job. No fabrication or manufacturing of items not installed by the applicant.
91405 - Carpet-Upholstery Cleaning
-No work involving new residential properties prior to the certificate of occupancy or planned in the future. No work away from
customers premises. No work on automobiles or RVs. No rental of equipment to others. No flood or water damage work extracting
water from carpets or upholstery.
91436 - Ceiling/Wall Installation - metal
-No structural work over 3 stories. No hillside construction (slopes greater than 20 degrees). No waterproofing. No roofing work. No
demolition (structural) of residence or commercial building. No retaining walls greater than 6 feet tall. No seismic retrofitting other
than shear walls or foundation bolting or does work constituting more than 20% of total operations. No EIFS work.
91551 - Communication Equipment Installation.
-No traffic signals or control work. No fire suppression or alarm work. No work on LPG gas lines or pumps. No industrial machinery
repair or installation (millwright work). No rental of equipment to others. No work more than 12 feet below grade. No
road/highway/bridge/overpass work. No work on security cameras or closed circuit TV's. No sales of items not installed by the
applicant.
91560 - Concrete Construction
-No foundation work or repairs. No underground horizontal boring or coring. No road/highway/bridge/overpass work. No structural
work over 3 stories. No EIFS work. No Dam or levee work. No underground tank work. No work more than 12 feet below grade. No
rental of equipment to others. No use of explosives. No demolition (structural). No underpinning or shoring. No hillside construction
(slopes greater than 20 degrees). No retaining walls greater than 6 feet tall. No waterproofing or application or epoxy or specialty
coatings. No installation or repair of sound walls.
91577 - Conduit Construction - cable/wire
-No work on gas lines, pumps or LPG. No process piping work. No industrial machinery repair or installation (millwright work). No
fire suppression or alarm work. No traffic signals or controls work. No hillside construction (slopes greater than 20 degrees). No work
more than 12 feet below grade. No road/highway/bridge/overpass work.
91629 - Debris Removal - construction site
-No janitorial work performed. No road/highway/bridge/overpass work. No environmental clean up. No demolition, interior or
exterior. No roofing tear off. No rental of equipment to others. No power washing. No removal of hazardous substances. No debris
removal not from construction sites. No salvage operations. No asbestos removal.
91746 - Door/Millwork Installation - metal
-No window installation or repair work. No work on self-closing fire doors. No rental of equipment to others. No retail store or
showroom exposures. No fabrication or manufacturing of items not installed by the applicant. No sales of items not installed by the
applicant.
92102 - Drilling - Water
-No drilling work for public drinking water. No work on gas lines, pumps, LPG, or oil fields. No environmental clean up. No dam or
levee work. No process piping work. No rental of equipment to others. No hillside construction (slopes greater than 20 degrees). No
underground tank work. No agricultural work. No pump repair work for wells.
92215 - Driveway/Sidewalk Pave
-No new or repair foundation work. No road/highway/bridge/overpass work. No traffic signals or controls work. No retaining walls
greater than 6 feet tall. No dam or levee work. No environmental clean up. No Rental of equipment to others. No Demolition
(structural). No underpinning or shoring. No hillside construction (slopes greater than 20 degrees). No application of epoxy or
specialty coatings or other waterproofing materials.
92338 - Drywall
-No new residential work or work within dormitories or student housing. No waterproofing. No exterior plastering or stucco. No
insulation work. No EIFS work. No demolition (structural). No environmental cleanup.

4

5
92478 - Electrical - within buildings
-No traffic signals or control work. No fire suppression or alarm work. No dam or levee work. No work outside of building. No rental
of equipment to others. No road/highway/bridge/overpass work. No work on generators or over 480 volts. No work on machinery or
production lines. No industrial electrical work. No underground work. No underground work. No pole to building work. No work on
security cameras or closed circuit TV's. No pool, sauna, jacuzzi or pond work. No solar panel work.
94007 - Excavation
-No work with explosives. No road/highway/bridge/overpass work. No underground tank work. No dam or levee work. No
environmental clean up. No work more than 12 feet below grade. No traffic signals or controls work. No work on gas lines, pumps, or
LPG. No Rental of equipment without operator to others. No demolition (structural). No underpinning or shoring. No hillside
construction (slopes greater than 20 degrees). No foundation work or repairs. No work in landfills. No work if the applicant is solely
paid by the hour. No swimming pool or pond work.
94276 - Fence Erection
-No fabrication of fencing. No hillside construction (slopes greater than 20 degrees). No road/highway/bridge/overpass work or work
on sound walls. No Installation and/or service of automated gates. No retaining walls greater than 6 feet tall. No rental of temporary
fencing or equipment to others. No dam or levee work. No decks, gezebos, or planters. No playground or bleacher work. No portable
child safety fences or pools. No sound wall installation or repair. No fabrication or manufacturing of items not installed by the
applicant. No sales of items not installed by the applicant.
94569 - Floor Covering - no tile
-No waterproofing or use of epoxy or specialty coatings. No rental of equipment to others. No tile installation. No application of slop
resistant flooring. No fabrication or manufacturing of items not installed by the applicant. No sales of items not installed by the
applicant.
95410 - Grading
-No work with explosives. No road/highway/bridge/overpass work. No underground tank work. No dam or levee work. No
environmental clean up. No work more than 12 feet below grade. No traffic signals or controls work. No work on gas lines, pumps, or
LPG. No work if the applicant is solely paid by the hour. No hillside construction (slopes greater than 20 degrees). No work in
landfills. No underpinning or shoring. No demolition (structural). No foundation work or repairs. No rental of equipment without
operator to others. No swimming pool or pond work. No agricultural work.
95647 - Heat/AC no LPG
-No work involving refrigeration systems other than cooling of air. No work on LPG gas lines or pumps. No crane work performed by
the applicant. No gutters, downspouts or flashing. No roofing. No sale of sheet metal products either wholesale or retail. No work on
automobiles or RV's. No environmental clean up. No Process piping. No industrial machinery repair or installation (millwright work).
No fire suppression or alarm work. No rental of equipment to others. No Underground tank work. No sheet metal work other than
ducting. No work on fireplaces, wood stoves or pellet stoves. No sales of items not installed by the applicant.
96053 - House Furnishings Installation
-No fire suppression or alarm work. No rental of equipment to others. No window installation or repair. No fabrication of products to
be installed. No retail store or showroom exposure. No fabrication or manufacturing of items not installed by the applicant. No sales of
items not installed by the applicant.
96816 - Janitorial-Commercial
-No work involving new residential properties prior to the certificate of occupancy or planned in the future. No commercial retail
work, restaurant work or work in any type of property other than commercial offices. No residential work, including for property
managers or for model homes. No sale of chemicals or cleaning supplies either retail or wholesale. No Industrial or manufacturing
including computer clean rooms. No floor waxing over 25%. No exterior window washing. No rental of equipment to others. No
cleaning of banks or financial institutions. No cleaning of medical offices, dental offices or hospitals. No power washing. No cleaning
of churches.
97047 - Landscape Gardening
-No road/highway/bridge/overpass work. No retaining walls greater than 6 feet tall. No construction of ponds or pools. No tree
trimming other than from the ground. No environmental clean up, no playground equipment/bleacher work. -No rental of equipment
to others. No waterproofing. No hillside construction (slopes greater than 20 degrees). No dam or levee work. No erosion control
work. No application of pesticides or herbicides.
97447 - Masonry
-No retaining walls greater than 6 feet tall. No structural work over 3 stories. No hillside construction (with slope of greater than 20
degrees). No work on swimming pools or decks of swimming pools. No waterproofing. No rental of equipment to others. No
demolition (structural). No work more then 12 feet below grade. No foundation work or repairs. No road/highway/bridge/overpass
work. No dam or levee work. No fireplace or chimney work. No sound wall installation or repair. No fabrication or manufacturing of
items not installed by the applicant.
97650 - Metal Erection - decorative
-No exterior work. No structural work. No welding to fabricate or install. No playground equipment or bleachers. No demolition work.
No retail store or showroom exposure. No fabrication or manufacturing of items not installed by the applicant. No sales of items not
installed by the applicant.
98304 - Paint Exterior (3 Stories & Under)
-No waterproofing or application of epoxy or specialty coatings. No exterior work over 3 stories. No road/highway/bridge/over pass
work. No painting or sealing of roof decks. No rental of equipment to others. No Painting of tanks or any items other than buildings.
98305 - Paint Interior
-No waterproofing or application of epoxy or specialty coatings. No exterior work over 3 stories. No road/highway/bridge/overpass
work. No painting or sealing of roof decks. No rental of equipment to others. No painting of tanks or items other than buildings.
98344 - Paperhanging
-No painting of interior walls. No work outside of building. No waterproofing or application of epoxy or specialty coatings. No rental
of equipment to others. No retail store or showroom exposure.

5

6
98449 - Plaster/Stucco
-No residential work or work within dormitories/student housing. No waterproofing or application of epoxy or specialty coatings. No
EIFS Work.
98482 - Plumbing Commercial
-No work deeper than 8 feet underground. No production line, manufacturing or water-sewer treatment plant work. No condo or
townhouse work. No welding work. No pool, sauna, jacuzzi or pond wok. No trenchless underground operations. No backflow testing.
98483 - Plumbing Residential
-No new residential work prior to the certificate of occupancy. No work deeper than 8 feet underground. No condo or townhouse
work. No welding work. No pool, sauna, jacuzzi or pond work. No trenchless underground operations. No backflow testing.
98502 - Prefabricated Building Erection
-Erection other than outbuilding, utility building or non-habitational free standing garages. No structural work over 1 story. No hillside
construction (with slope of greater than 20 degrees). No rental of equipment to others. No demolition (structural). No underpinning or
shoring. No seismic retrofitting other than shear walls or foundation bolting or does work constituting more than 20% of total
operations.
98636 - Refrigeration Equipment Installation/Service
-No industrial machinery repair or installation (millwright work). No process of piping/cold food storage/packing plants. No work on
LPG gas lines or pumps. No environmental clean up. No rental of equipment to others. No underground tank work.
99650 - Satellite Dish Installation
-No work involving new residential properties prior to the certificate of occupancy or planned in the future. No residential roof top
work (excluding soffits). No work on towers. No rental of equipment to others. No road/highway/bridge/overpass work. No work
involving any thing other than television / radio communication. No sale of items not installed by the applicant.
98805 - Septic Tank Cleaning
-No recreational vehicles or trailers. No rental of portable restroom facilities. No repair of septic tanks or sanitary systems. No
environmental clean up. No rental of equipment to others.
98806 - Septic Tank Installation
-No use of explosives. No pumping or cleaning service not related to installation. No work on gas lines, pumps or LPG. No
environmental clean up. No work more than 12 feet below grade. No rental of equipment to others. No hillside construction (slopes
greater than 20 degrees).
98820 - Sewer Mains Construction
-No work more than 12 feet below grade. No work on gas lines, pumps, or LPG. No use of explosives. No environmental clean up. No
process piping work. No rental of equipment to others. No hillside construction (slopes greater than 20 degrees). No
road/highway/bridge/overpass work. No underground tank work. No dam or levee work. No responsibility for setting up traffic
controls when working in public streets. No trenchless underground operations.
98967 - Siding and Gutter Installation
-No new residential work prior to the certificate of occupancy. No roofing flashings or roofing work. No demolition work. No EIFS
work. No fabrication of gutters that are not installed by the applicant. No fabrication or manufacturing of items not installed by the
applicant. No sales of items not installed by the applicant.
99004 - Sign Painting
-No exterior sign painting above 2 stories. No work on roads, highways, overpasses or bridges. No work performed involving
vehicles.
99746 - Title/Stone Installation
-No retaining walls greater than 6 feet tall. No hillside construction (slopes greater than 20 degrees). No structural work over 3 stories.
No work on swimming pools or decks of swimming pools. No roofing. No waterproofing or application of epoxy or specialty
coatings. No rental of equipment to others. No foundation work or repairs. No fabrication or manufacturing of items not installed by
the applicant. No sales of items not installed by the applicant.
99946 - Water Mains Construction
-No work on gas lines, pumps, or LPG. No work more than 12 feet below grade. No use of explosives. No underground tank work. No
environmental clean up. No process piping work. No rental of equipment to others. No hillside construction (slopes greater than 20
degrees). No road/highway/bridge/overpass work. No dam or levee work. No trenchless underground operations. No responsibility for
setting up traffic controls when working in public streets.

Acceptance:
™
™
™
™
™

I understand that absolutely no insurance of any kind whatsoever is being applied for other than the insurance coverage I
have requested in this application.
I warrant that all the information provided by me and my authorized agent is true and correct. I also understand that if any
of the information provided in this application is not true then any and all insurance coverage will be void from the
effective date of the insurance coverage.
I also understand that if any of the information provided to the insurance company in this application turns out to be false,
my insurance policy may be cancelled at any time at the option of the insurance company.
I warrant that all the information contained on this application is the truth. I agree to advise Worldwide Insurance
Specialists, Inc. of any changes in the information provided and set forth on this application.
I have read and understand this entire application.

________________________________________________
Signature of Authorized Agent or Insured:

6


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