3rd Millennium Insurance & Financial Services, Inc. Appointed Brokers for ProBuilders Specialty Insurance, RRG CONTRACTORS APPLICATION 8116 One Calais Ave., Suite 2A Baton Rouge, LA  70809 FAX:  (225) 757-2257 contractors@3rdmillennium-ins.com     SUBPRODUCER   NAME:   TELEPHONE: FAX:   ADDRESS: CITY: STATE: ZIP CODE:   PROPOSED EFFECTIVE DATE: PROPOSED EXPIRATION DATE:   APPLICANT INFORMATION   NAME (First Named Insured & Other Named Insureds)   FEIN OR SSN:   TELEPHONE:   MAILING ADDRESS (Of First Named Insured):   CITY: STATE: ZIP CODE:   EMAIL ADDRESS(ES): WEBSITE:   INDIVIDUAL CORPORATION NOT FOR PROFIT PARTNERSHIP JOINT VENTURE LLC OTHER   YEARS IN BUSINESS (Principals) YEARS AS CURRENT ENTITY YEARS EXPERIENCE (In Trade)   INSPECTIONS CONTACT: TELEPHONE:   ACCOUNTING RECORDS CONTACT: TELEPHONE:   LOCATION INFORMATION   LOC # Address City State Zip Code Occupancy/Operations           NATURE OF BUSINESS (INCLUDE DESCRIPTION OF OPERATIONS AND OWNERSHIP OF EACH ENTITY AND EACH PREMISES)   CONTRACTOR'S LICENSE STATE(S):   CONTRACTOR'S LICENSE NUMBER(S):   HOME BUILDERS ASSOCIATION: (Please check)   ASHBA BANN BAWN CAHB HBAT WRMBA N/A Other:   MEMBER NUMBER (IF APPLICABLE):   GENERAL INFORMATION (EXPLAIN ALL "YES" RESPONSES)   YES NO 1 IS THE APPLICANT A SUBSIDIARY OF ANOTHER ENTITY OR DOES THE APPLICANT HAVE ANY SUBSIDIARIES? 2 DOES APPLICANT LEASE EQUIPMENT TO OTHERS WITH OR WITHOUT OPERATORS? 3 DOES APPLICANT HAVE A FORMAL SAFETY PROGRAM IN OPERATION? 4 DOES APPLICANT HAVE ANY EXPOSURE TO FLAMMABLES, EXPLOSIVES, CHEMICALS? 5 DOES APPLICANT HAVE ANY CATASTROPHE EXPOSURE? 6 HAS APPLICANT HAD ANY POLICY, BOND OR COVERAGE DECLINED, CANCELLED OR NON-RENEWED DURING THE PRIOR THREE YEARS? 7 DOES APPLICANT HAVE ANY PAST LOSSES OR CLAIMS INVOLVING SEXUAL ABUSE OR MOLESTATION ALLEGATIONS, DISCRIMINATION OR NEGLIGENT HIRING? 8 DOES APPLICANT HAVE ANY BANKRUPTCIES, TAX OR CREDIT LIENS AGAINST THE APPLICANT IN THE PAST FIVE YEARS? 9 HAS ANY LOCAL, STATE OR FEDERAL GOVERNMENT AGENCY OR LICENSING BOARD CITED THE APPLICANT FOR VIOLATION OF ANY LAW OR REGULATION OR INVESTIGATED YOU IN THE PAST FIVE YEARS? 10 DOES APPLICANT HAVE ANY OPERATIONS OTHER THAN CONTRACTING? 11 HAS APPLICANT IN THE PAST OR DOES APPLICANT CURRENTLY DO BUSINESS UNDER ANY NAME OTHER THAN THE NAMES LISTED PREVIOUSLY ON THIS APPLICATION? 12 DOES APPLICANT DRAW PLANS, DESIGNS OR SPECIFICATIONS FOR OTHERS? 13 HAS APPLICANT OR DOES APPLICANT PLAN TO HAVE OPERATIONS OUTSIDE CONTRACTOR'S LICENSE STATE(S) LISTED ABOVE? 14 DO APPLICANT OR APPLICANT'S EMPLOYEES WORK OR PLAN TO WORK UNDER THE  USL&H ACT OR THE JONES ACT (MARITIME WORK)? 15 DOES APPLICANT OR WILL APPLICANT ALLOW CONTRACTOR'S LICENSE TO BE USED BY OTHER CONTRACTORS? 16 DOES APPLICANT ALLOW ANY SUBCONTRACTORS TO MAINTAIN LIMITS OF LIABILITY LESS THAN THAT OF THE APPLICANT? 17 ARE SUBCONTRACTORS ALLOWED TO WORK WITHOUT PROVIDING APPLICANT WITH A CERTIFICATE OF INSURANCE? 18 DOES APPLICANT ALLOW ANY SUBCONTRACTORS TO MAINTAIN COVERAGE WITH MORE RESTRICTIVE COVERAGE THAN THE APPLICANT'S? (EXPLAIN ALL "NO" RESPONSES)   YES NO 19 DOES APPLICANT PLAN OR HAS APPLICANT EVER SUBCONTRACTED WORK TO OTHERS? 20 DOES OR WILL APPLICANT HAVE A WRITTEN CONTRACT WITH ITS SUBCONTRACTORS THAT INCLUDES A HOLD HARMLESS AGREEMENT RELATIVE TO  WORK PERFORMED BY THE SUBCONTRACTOR? 21 IS APPLICANT NAMED AS ADDITIONAL INSURED ON ITS SUBCONTRACTORS' INSURANCE POLICIES? 22 DOES APPLICANT ALWAYS CHECK WITH LOCAL UTILITY AUTHORITIES BEFORE DIGGING? 23 DOES APPLICANT CARRY WORKERS COMPENSATION FOR ALL EMPLOYEES? 24 DOES THE APPLICANT FOLLOW THE PROVISIONS OF ANY LAW OR REGULATION GIVING BUILDERS THE RIGHT TO CORRECT DEFECTS IN CONSTRUCTION (SOMETIMES KNOWN AS “RIGHT TO CURE” LAWS)? REMARKS:   PRIOR CARRIER INFORMATION COMMERCIAL GENERAL LIABILITY CARRIER POLICY NUMBER POLICY TYPE CLAIMS MADE OCCURRENCE CLAIMS MADE OCCURRENCE CLAIMS MADE OCCURRENCE CLAIMS MADE OCCURRENCE CLAIMS MADE OCCURRENCE EFF.-EXP. DATE  GENERAL AGGREGATE PRODUCTS/ COMP. OPS. AGGREGATE PERSONAL & ADV. INJ. EACH OCCURRENCE FIRE DAMAGE MEDICAL EXPENSE DEDUCTIBLE RECEIPTS TOTAL PREMIUM   LOSS HISTORY SUMMARY EFF.-EXP. DATE TOTAL LOSSES ($) NUMBER OF CLAIMS VALUATION DATE   ENTER ALL GENERAL LIABILITY CLAIMS OR LOSSES (REGARDLESS OF FAULT AND WHETHER OR NOT INSURED) FOR THE PRIOR FIVE YEARS. CHECK HERE IF NONE SEE ATTACHED LOSS SUMMARY DATE OF OCCURRENCE LINE TYPE / DESCRIPTION OF OCCURRENCE OR CLAIM DATE OF CLAIMS AMOUNT PAID AMOUNT RESERVED CLAIM STATUS OPEN CLOSED OPEN CLOSED OPEN CLOSED OPEN CLOSED OPEN CLOSED OPEN CLOSED OPEN CLOSED REMARKS: DESCRIBE ANY MEASURES TAKEN TO PREVENT REOCCURRENCE OF SIMILAR CLAIMS:   (EXPLAIN ALL "YES" RESPONSES)   YES NO 1 IS THE APPLICANT 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)? 2 WITHIN THE LAST FIVE YEARS HAS THE APPLICANT BEEN NAMED IN LITIGATION REGARDING FAULTY CONSTRUCTION? 3 WITHIN THE LAST TEN YEARS, HAS ANY PERSON OR ENTITY DEMANDED THAT YOU DEFEND THEM, OR HOLD THEM HARMLESS, IN ANY CLAIM OR LAWSUIT? 4 WITHIN THE LAST FIVE YEARS HAS ANY LAWSUIT BEEN FILED, OR CLAIM OTHERWISE BEEN MADE, AGAINST THE APPLICANT OR ANY COMPANY OR ANY PARTNERSHIP OR JOINT VENTURE OF WHICH THE APPLICANT HAS BEEN A MEMBER, OR THE APPLICANT'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 INCLUDES RECEIPT OF A DEMAND FOR MONEY, SERVICES, ARBITRATION OR MEDIATION. REMARKS:   COVERAGE INFORMATION LIMITS EACH OCCURRENCE LIMIT GENERAL AGGREGATE LIMIT PRODUCTS/COMPLETED OPERATIONS AGGREGATE LIMIT PERSONAL & ADVERTISING INJURY LIMIT DAMAGE TO PREMISES RENTED BY YOU LIMIT MEDICAL EXPENSE LIMIT   COVERAGE OPTIONS BLANKET ADDITIONAL INSURED ENDORSEMENT SCHEDULED ADDITIONAL INSURED ENDORSEMENT* #: WAIVER OF SUBROGATION ENDORSEMENT EXTENDED COVERAGE ENDORSEMENT MOBILE EQUIPMENT COVERAGE ENDORSEMENT AIRCRAFT, WATERCRAFT OR AUTO COVERAGE ENDORSEMENT