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6049335-341881Owners and Contractors Protective Liability Application Please complete the required fields below and submit in the Electronic Business Center selecting Owners & Contractors/Railroad Protective Liability under the Start a Quote / Select a Quoting Tool. Along with this application, please include the following additionalInformation. A copy of the contract(s) for the projectIf The Hartford does not write the underlying General Liability policy for the Designated Contractor, please provideA minimum of 5 years primary General Liability loss runs for the Designated Contractor valued within last 90 daysSubmit a sample executed subcontract agreement for the project if work is subcontracted by the Designated Contractor Please send any additional information required above to Construction-ocp-rrp@A. General InformationWhat is the project’s nature of operations? FORMCHECKBOX Construction, FORMCHECKBOX Janitorial, FORMCHECKBOX Land Ownership, FORMCHECKBOX Landscaping, FORMCHECKBOX Manufacturing, FORMCHECKBOX Service/Maintenance Work Only, FORMCHECKBOX Snow Removal, FORMCHECKBOX Work Required for Permits, FORMCHECKBOX OtherHas the designated contractor been in business for 5 or more years? FORMCHECKBOX Yes FORMCHECKBOX NoIs 6-foot fall protection enforced for all employees and subcontractor employees, including steel workers? FORMCHECKBOX Yes FORMCHECKBOX NoIs the project in the state of New York? FORMCHECKBOX Yes FORMCHECKBOX NoDoes this project involve blasting? FORMCHECKBOX Yes FORMCHECKBOX NoIs The Hartford your designated contractor’s General Liability carrier? FORMCHECKBOX Yes FORMCHECKBOX No If not insured by The Hartford for GL, does this project involve road work? FORMCHECKBOX Yes FORMCHECKBOX No Who is the named insured (Project Owner)? FORMTEXT ?????Named Insured (Project Owner) Address: FORMTEXT ?????Designated Contractor’s Name: FORMTEXT ?????Designated Contractor Address: FORMTEXT ?????Who is the designated contractor working for? FORMCHECKBOX Another contractor, FORMCHECKBOX OwnerDescribe the Project below: FORMTEXT ?????Is the project: New Construction FORMCHECKBOX or Renovation/Restoration FORMCHECKBOX If Renovation does the work involve structural or vertical concrete repair/restoration? FORMCHECKBOX Yes FORMCHECKBOX No What is the main project address? FORMTEXT ?????How many project locations are there? FORMCHECKBOX 1, FORMCHECKBOX 2-5, FORMCHECKBOX 6+B. Designated Contractor Loss Information – Please answer the following based on primary General Liability loss runs for the designated contractor valued within 90 days.Have there been more than 5 GL Premises claims in any annual policy term? FORMCHECKBOX Yes FORMCHECKBOX No Has there been more than $250,000 total incurred GL Premises claims (all years) over the most recent 5-year period? FORMCHECKBOX Yes FORMCHECKBOX NoHas there been any single GL Premises loss greater than $100,000 over the most recent 5 years? FORMCHECKBOX Yes FORMCHECKBOX NoC. Project DetailsJob/Project number (optional): FORMTEXT ?????Bid date (optional): FORMTEXT ?????Proposed start (eff) date FORMTEXT ?????Planned completion (exp) date: FORMTEXT ?????What is the total estimated project cost?$ FORMTEXT ?????Is Work being subcontracted out? FORMCHECKBOX Yes FORMCHECKBOX NoIf Yes, what is the subcontract Cost$ FORMTEXT ?????Does the subcontractor agreement (which will be required when requesting coverage) require subcontractors to provide? $1M/$2M GL limits on a per project basis and umbrella of $1M with no exclusions for the scope of the work that the sub performs? FORMCHECKBOX Yes FORMCHECKBOX No Additional Insured coverage to our insured and to the Project Owner using CG2010? FORMCHECKBOX Yes FORMCHECKBOX No Additional Insured coverage to our insured and Project Owner coverage primary and on a noncontributory basis which also includes a waiver of subrogation provision? FORMCHECKBOX Yes FORMCHECKBOX No Hold Harmless and Indemnification from all liability caused by the subcontractor’s or lower tier subcontractors acts, omissions, or negligence, including any defense costs/attorney fees? FORMCHECKBOX Yes FORMCHECKBOX No What are the working hours? FORMCHECKBOX Peak, FORMCHECKBOX Off Peak, FORMCHECKBOX CombinationIs the location fenced off/separated from other properties and the public? FORMCHECKBOX Yes FORMCHECKBOX NoHow is the jobsite supervised (check all that apply)? FORMCHECKBOX Full time project supervisor FORMCHECKBOX Regular safety inspections FORMCHECKBOX Project owner actively involved in management or supervision FORMCHECKBOX None of the AboveIs the work confined to building interiors only? FORMCHECKBOX Yes FORMCHECKBOX NoIf Yes above, is the building occupied during the project? FORMCHECKBOX Yes FORMCHECKBOX No If No to interior work only (skip to the coverages section if Yes to interior only):Does this project involve road work? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, to road work, what type of roadways? FORMCHECKBOX High Speed, FORMCHECKBOX Low Speed, FORMCHECKBOX CombinationWhat is the vehicular (auto/boat) traffic like? FORMCHECKBOX High, FORMCHECKBOX Medium, FORMCHECKBOX Low, FORMCHECKBOX Not ApplicableIs Traffic control required FORMCHECKBOX Yes FORMCHECKBOX NoIf Yes, who performs traffic control? FORMCHECKBOX Self-Performed, FORMCHECKBOX Subcontracted, FORMCHECKBOX CombinationWhat is pedestrian traffic like? FORMCHECKBOX High, FORMCHECKBOX Medium, FORMCHECKBOX Low, FORMCHECKBOX Not ApplicableDoes this work involve a bridge, dam, tunnel, or trestle greater than 250 feet? FORMCHECKBOX Yes FORMCHECKBOX NoDoes this work involve structural wrecking or demolition? FORMCHECKBOX Yes FORMCHECKBOX NoDoes this work involve potential exposure to hazardous materials or pollution? FORMCHECKBOX Yes FORMCHECKBOX NoDoes this work involve pile driving within 1 mile of other buildings, equipment, or structures? FORMCHECKBOX Yes FORMCHECKBOX NoDoes this work involve excavation? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, is the excavation greater than 3 feet deep, 3 feet in diameter, or 50 feet long? FORMCHECKBOX Yes FORMCHECKBOX NoDoes project involve work on or around gas utility lines? FORMCHECKBOX Yes FORMCHECKBOX NoDoes this work involve hot work in Wildfire Prone Areas? FORMCHECKBOX Yes FORMCHECKBOX NoD. CoveragesWhat are the OCP Limits requested?Occurrence:$ FORMTEXT ?????Aggregate:$ FORMTEXT ?????Is The Hartford your designated contractor's General Liability carrier? FORMCHECKBOX Yes FORMCHECKBOX NoIf no, who is the General Liability carrier? FORMTEXT ?????Is the Hartford your designated contractor’s Umbrella carrier? FORMCHECKBOX Yes FORMCHECKBOX NoIf no, who is the Umbrella carrier? FORMTEXT ?????E. Additional CommentsIf you have additional comments, please do so in the box below: FORMTEXT ?????F. SignatureI, being duly authorized by the company applying for coverage, declare that to the best of my knowledge and belief all of the foregoing statements are true, and that these statements are offered as an inducement to the Company to issue the policy for which I am applying.Insured Signature: FORMTEXT ?????Title: FORMTEXT ?????Date: FORMTEXT ?????Insured Name: FORMTEXT ?????Producer Signature: FORMTEXT ?????Title: FORMTEXT ?????Date: FORMTEXT ?????Producer Name: FORMTEXT ?????License Identification Number or Producer Number: FORMTEXT ????? (Florida Producers must Provide License Identification Number)This application is for the purposes of obtaining insurance coverage with The Hartford Insurance Group which mayinclude any of the following companies.First State Insurance CompanyHartford Accident and Indemnify CompanyHartford Casualty Insurance CompanyHartford Fire Insurance CompanyHartford Insurance Company of IllinoisHartford Insurance Company of the MidwestHartford Insurance Company of the SoutheastHartford Lloyd's Insurance CompanyHartford Underwriters Insurance CompanyNew England insurance companyNew England Reinsurance CorporationNutmeg Insurance CompanyOmni Indemnify CompanyOmni Insurance CompanyPacific Insurance Company, LimitedProperty and Casualty Insurance Company of Hartford Sentinel Insurance Company, ltdTrumbull Insurance CompanyTwin City Fire Insurance CompanyFraud Warning StatementsKnowingly presenting false or misleading information in an application for insurance may be a crime and violation of law subjecting the applicant to criminal and civil penalties.Arkansas, Louisiana, Rhode Island and West Virginia applicants: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.Alabama applicants: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution, fines, or confinement in prison, or any combination thereof.California applicants:? For your protection California law requires the following to appear on this form: Any person who knowingly presents false or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.Colorado applicants: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.District of Columbia applicants: Warning: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.Florida applicants: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.Hawaii applicants: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both.Kentucky applicants: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.Maine applicants: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.Maryland applicants: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.New Jersey applicants: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.New Mexico applicants: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.New York applicants: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, and any person who, in connection with such application or claim, knowingly makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, damage or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or an insurance company, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the value of the subject motor vehicle or the stated value of the claim for each such violation.Ohio applicants: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.Oklahoma applicants: Warning: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.Oregon applicants: Any person who knowingly and with intent to defraud or solicit another to defraud an insurer: (1) by submitting an application or; (2) filing a claim containing a false statement as to any material fact may be violating state law.Arbitration StatementApplicable to Utah applicants: If the policy will contain an arbitration clause: Any matter in dispute between you and the company may be subject to arbitration as an alternative to court action pursuant to the rules of the (American arbitration Association or other recognized arbitrator), a copy of which is available on request from the company. Any decision reached by arbitration shall be binding upon both you and the company. The arbitration award may include attorney's fees if allowed by state law and may be entered as a judgment in any court of proper jurisdiction. ................
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