GCGuard - REInsurePro - Proposal Request

Agency/Producer Information

Note: Your privacy is very important to us. To better serve you, the form information you enter is recorded in real time.

Agency Name*

Agency Address

Address Line 1

City

State

ZIP Code

Agency Phone*

Producer Name*

First Name

Last Name

Producer OR Account Manager email*

Confirmation email will be sent here.

Producer Phone*

Applicant Information

Named Insured*

First Name Insured and dba, if applicable

Business Structure*

Inspection Contact*

First Name

Last Name

FEIN or Last 4 digits of SSN

Desired Policy Effective Date *

Quote Need By Date*

Please Note: In order to best serve you and strengthen the carrier relationships we can provide you, same day turnarounds are only available for very limited submissions. PLEASE provide a genuine expiration date (if known) and a realistic need-by date. We will do our best to accommodate RUSH orders.

Applicant Mailing Address*

Address Line 1

City

State

ZIP Code

Applicant Phone Number*

Applicant Website Address*

N/A or "None" if no website exists

Applicant Email*

Year Business was Founded*

Is current GL coverage in place?*

Has the applicant operated without insurance? (Personal renovation projects do not apply)*

NOTICE FOR NEW VENTURE APPLICANTS:

GCGuard IS a market for new ventures in the trades and general contractor space!

In order to complete a submission to our carrier partners, many are requiring resumes of the owners.

A file upload option is provided at the end of this application. If a resume is not currently available, you may provide one via email to programs@reinsurepro.com, however, some carriers will not offer a quote without one.

Explain any lapse in coverage

Last date coverage was in effect:

Years of experience in trade*

Licensed?*

Kind of License and Number:

Year License Issued

No. of Active Owners & Officers*

Number of Employees*

Does the applicant own more than 50 percent of another business than the one described*

Is applicant a subsidiary or parent of another company?*

Explain*

Is applicant or member of any local, regional or national contractors or trade associations?

List any relevant current membership.

EX: NARI, NRCA, NECA, etc

Does applicant hold any certifications, degrees, or continuing education credits?

List any relevant certifications.

EX: CAPS, OSHA, CCM, CEM, Etc.

Does agent control this account?*

Current carrier and annual premium?

Reason for marketing account if not prospecting or not a new venture.

Application to be considered for the following lines:

Check all that apply:*

General Liability Workers Compensation IM - Misc. Tool Floater (Blanket except tools valued >$1,000 must be scheduled) IM - Contractor's Equipment (Can include blanket for Misc. Tools) Bonds - License, Permit or Dishonesty Excess Liability Building or Business Personal Property, including Business Interruption

General Liability Target Premium

Work Comp Target Premium

IM Target Premium

Excess Liability Limits Requested

Property Target Premium

Contractor's Supplemental Application

Please Complete the Online application. You will receive a copy along with your confirmation email.

Questions for each selected line of coverage are included. Trade-specific supplementary apps may be required.

Loss runs required if any loss in last 3 years.

Application Options*

Complete Online Application-You will receive a copy for your files Upload another carrier supplemental application I have on file Upload GCGuard application

NOTE: ACORD 125 & 126 are required prior to binding

Contractor's Supplemental Application

No File Chosen

File uploads may not work on some mobile devices.

After upload, click "Next" to complete your application and submit. Please remove or redact any personally identifiable information we do not require from documents before uploading.

Underwriting Questions

Are subcontractors allowed to work without providing you with a certificate of insurance?*

Please elaborate the frequency, work done, and conditions under which uninsured subs are hired.*

Are certificates of insurance obtained from subcontractors?*

Are written contracts obtained from all subcontractors which include a hold harmless clause in your favor?*

Do you require a minimum of $1M per occurrence?*

If no, explain when not required

Are you named as an additional insured on all subcontractors' policies?*

Are any additional insureds to be added to your policy?*

Please provide at binding

Please explain who you provide additional insured status to:

Do you have a formal safety program in operation?*

Please explain safety program or provide a copy of insured’s safety manual.

A copy of safety program may be required as a subjectivity to binding

Your Scope of Work

On the following page, please complete each Scope of Work section.

NUMBER OF PROJECTS-Residential and Commercial

Questions below relate to the number of houses, units, or projects you have been, or expect to be engaged in.

NOTE: Many carriers have strict limitations for multiple projects in new, tract home developments. Please ensure you are accurately depicting any tract home development work.

Total # of Residential Jobs - Last 12 months*

How many residential jobs or projects were worked on last year

# of Residential Jobs in a Single (New Tract) Development - Last 12 months*

How many houses or units in a single development were worked on last year

# Commercial Jobs- Last 12 months*

How many commercial jobs or projects were worked on last year

Total # Residential Jobs - Next 12 months*

# Estimated residential jobs or projects in next 12 months

# Residential Jobs in a Single (New Tract) Development - Next 12 months*

# Estimated jobs, houses or units in a single development in the next 12 months

# Commercial Jobs - Next 12 months*

# Estimated commercial jobs or projects in next 12 months

Anticipated Number of Ground-Up New Construction Projects - Next 12 months*

Have you ever been involved as a General Contractor in the building of Residential Homes, Condominiums, Townhouses or Apartment Buildings*

Do you own any Vacant or Real Estate Development Land?*

If yes, maximum number built during any 12-month period during the last five years*

Please describe location, zoning type and intended purpose of vacant land:*

BUILD, REMODEL, REPAIR SCOPES:

Indicate the percentage of work performed by you and your subs in the following phases:

(Must equal 100%)

% New Construction or New Builds*

Percentage of Annual Receipts

% Structural Remodeling*

Percentage of Annual Receipts

% Non-Structural Remodeling*

Percentage of Annual Receipts

% Repair or Service*

Percentage of Annual Receipts

% Other Work*

Percentage of Annual Receipts

Describe "Other"*

Total Build/Remodel/Repair Scopes

Please ensure all fields above total 100%.

RESIDENTIAL, COMMERCIAL, INDUSTRIAL SCOPES:

Allocate the percentage of your gross annual receipts, performed by you and your subs to client/project owner types:

(Must equal 100%)

% Residential Projects*

% of Annual Projects

% Commercial Projects*

% of Annual Projects

% Industrial Projects*

% of Annual Projects

% Municipalities Projects*

% of Annual Projects

% Petro/Chemical Projects*

% of Annual Projects

% Airports or Hospital Projects*

% of Annual Projects

Please ensure all fields above total 100%.

Please provide examples of commercial clients*

Please provide examples of industrial clients*

Please describe work done for municipalities and government entities*

Residential/Commercial Scopes

INTERIOR, EXTERIOR SCOPE OF WORK:

Indicate the percentage of work performed by you and your subs - interior vs exterior:

(Must equal 100%)

% Interior Work*

% of work done inside

% Exterior Work*

% of work done outside

Total Interior/Exterior Scope

Please ensure all fields above total 100%.

Describe your LARGEST PROJECTS that you have performed during the past five years, including cost:*

Any exterior work performed above 3 stories in height?*

If yes, maximum # of stories?

Are cranes used by either you, your employees or your subcontractors?*

Is scaffolding used by either you, your employees or your subcontractors?*

Any work performed below grade?*

Maximum Depth*

% of total work*

Work Comp Payroll Allocations-Construction Trades

Trade Performed by Employees, including Drivers (1)*

Trade Performed must match each Anticipated Trade Performed by employees noted previously.

# Full Time Employees*

# Part Time Employees*

% of construction-related payroll*

Payroll in this Class* $

Calculated field. Total payroll for all construction-related trades must equal total projected payroll.

Add another work comp class*

Trade Performed by Employees, including Drivers (2)*

Trade Performed must match each Anticipated Trade Performed by employees noted previously.

# Full Time Employees*

# Part Time Employees*

% of construction-related payroll*

Payroll in this Class $

Calculated field. Total payroll for all construction-related trades must equal total projected payroll.

Add another work comp class*

Trade Performed by Employees, including Drivers (3)*

Trade Performed must match each Anticipated Trade Performed by employees noted previously.

# Full Time Employees*

# Part Time Employees*

% of construction-related payroll*

Payroll in this Class* $

Calculated field. Total payroll for all construction-related trades must equal total projected payroll.

Add another work comp class*

Trade Performed by Employees, including Drivers (4)*

Trade Performed must match each Anticipated Trade Performed by employees noted previously.

# Full Time Employees*

# Part Time Employees*

% of construction-related payroll*

Payroll in this Class $

Calculated field. Total payroll for all construction-related trades must equal total projected payroll.

Add another work comp class*

Trade Performed by Employees, including Drivers (5)*

Trade Performed must match each Anticipated Trade Performed by employees noted previously.

# Full Time Employees*

# Part Time Employees*

% of construction-related payroll*

Payroll in this Class $

Calculated field. Total payroll for all construction-related trades must equal total projected payroll.

Add another work comp class*

Clerical, office and miscellaneous payroll

Workers Compensation Classification*

Non-construction trade payroll. Drivers are included in the construction trade classification.

Describe "Other"*

# Full Time Employees*

# Part Time Employees*

Projected Annual Payroll* $

Add another work comp class*

Workers Compensation Classification*

Non-construction trade payroll. Drivers are included in the construction trade classification.

Describe "Other"*

# Full Time Employees*

# Part Time Employees*

Projected Annual Payroll* $

Add another work comp class*

Individuals Included/Excluded

Name*

First Name

Last Name

Title*

Email*

Included/Excluded*

Ownership %*

Trades/Operations Performed

Annual Payroll $

Add another individual to be Included/Excluded*

Name

First Name

Last Name

Title

Included/Excluded

Ownership %

Trades/Operations Performed

Annual Payroll $

Add another individual to be Included/Excluded*

Building and BPP Limits, Coverage, Property Details

Location Address*

Address Line 1

City

State

ZIP Code

Building Limit* $

Building Valuation*

ACV RCV

Business Personal Property* $

For business personal property on premise only. Tools and equipment on jobsites and in transit should be written on an inland marine policy.

BPP Valuation*

ACV RCV

Business Income Limit*

Business Income coverage is triggered when business operations are interrupted due to a covered cause of loss to covered building or BPP.

Total Insured Values $

Calculated field. Building, BPP

Coverage Form*

Deductible*

Construction*

Year Built*

Number of Stories*

Square Footage*

Burglar Alarm*

Fire Alarm*

Sprinkler System*

Building Updates*

Describe type and year of updates*

Wiring, Heating, Plumbing, Roof

Upload Property Schedule for Additional Locations

No File Chosen

File uploads may not work on some mobile devices.

Insured’s Loss History

Please advise of any losses in last 3 years:*

No Losses - New Venture. NKLL will be provided No Losses with history-Loss Runs will be provided General Liability Loss(es) WC Loss(es)- If application includes WC submission

Other:

Currently valued loss runs required if any losses in the past 3 years AT SUBMISSION. Letter of No Known Loss for new ventures required at binding.

Please explain any losses in the last three years. Please provide steps taken to prevent future losses. Hard copy loss runs MUST be uploaded with submission.*

Loss runs must be provided with submission if any losses are reported.

Have you ever had a Construction Defect loss/claim, been named in litigation alleging faulty construction, construction defects or mold, or been involved in a class action Construction Defect suit?*

Have any events occurred prior to the proposed effective date that may result in a claim?*

Please explain any Construction Defect loss or claim:

Describe any events prior to the proposed effective date that may result in a claim.

Have you ever done any work in AZ, CA, CO, NV, OR, TX or WA?*

Years worked there and type of work done:

Do you hold other person's property for service, storage, or repair?*

Does applicant have Workers' Compensation coverage in force?*

Does applicant lease employees to or from other employers?*

During the past three years has any company ever canceled, non-renewed, declined or refused to issue similar insurance to the applicant?*

Explain any cancellation, nonrenewal, declination or refusal to issue similar insurance:*

Does the applicant own/lease/operate any drones*

Does the applicant hire others to operate drones*

PLEASE REMOVE OR REDACT ANY PERSONALLY IDENTIFIABLE INFORMATION BEFORE UPLOAD.

We do not require Social Security Numbers, dates of birth, or other PII that may be contained on your ACORD forms.

Upload 3-5 Years Loss Runs*

No File Chosen

File uploads may not work on some mobile devices.

Required with application if any losses have been reported in last 5 years.

Upload File or Document

No File Chosen

File uploads may not work on some mobile devices.

(Optional)

Upload File or Document

No File Chosen

File uploads may not work on some mobile devices.

(Optional)

Upload File or Document

No File Chosen

File uploads may not work on some mobile devices.

(Optional)

Upload File or Document

No File Chosen

File uploads may not work on some mobile devices.

(Optional)

Will client request premium financing?

For best service, premium financing elections should be made at time of binding.

Disclosure and Signature

Fraud Statements

Applicable in AL, AR, DC, LA, MD, NM, RI and WV
Any person who knowingly (or willfully)* presents a false or fraudulent claim for payment of a loss or benefit or 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. *Applies in MD Only.

Applicable in CO
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 policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder 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.

Applicable in FL and OK
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)*. *Applies in FL Only.

Applicable in KS
Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written, electronic, electronic impulse, facsimile, magnetic, oral, or telephonic communication or statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act.

Applicable in KY, NY, OH and PA
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 commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties (not to exceed five thousand dollars and the stated value of the claim for each such violation)*.*Applies in NY Only.

Applicable in ME, TN, VA and WA
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 and denial of insurance benefits. *Applies in ME Only.

Applicable in NJ
Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

Applicable in OR
Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a false statement as to any material fact may be violating state law.

Applicant Name and Title*

Applicant Signature

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Signature Date

Campaign Source

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Campaign Term

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Campaign Name

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Progress

Agency/Producer Information

Applicant Information

Application to be considered for the following lines:

Critical Operations and Hazards performed by you or your subs

Contractor's Supplemental Application

General Liability Application

Estimated Payroll and Costs - Next 12 Months

Provide the Percentage (%) of Your Gross Receipts in Each of the Following Roles

Break out ALL trades & operations performed by you, your employees or your subcontractors.

Underwriting Questions

Your Scope of Work

NUMBER OF PROJECTS-Residential and Commercial

BUILD, REMODEL, REPAIR SCOPES:

RESIDENTIAL, COMMERCIAL, INDUSTRIAL SCOPES:

INTERIOR, EXTERIOR SCOPE OF WORK:

Work Comp Payroll Allocations-Construction Trades

Clerical, office and miscellaneous payroll

Individuals Included/Excluded

Miscellaneous Tools and Contractor's Equipment Application

Building and BPP Limits, Coverage, Property Details

Insured’s Loss History

Disclosure and Signature