NARI - National Association of The Remodeling Industry

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GENERAL LIABILITY

1. Current Carrier Name:

2. Date Policy Expires:

3. Number of years with current carrier Please Select 1 2 3 4 5 6 7 8 9 10 >10

4. Years of continuous coverage: Please Select 1 2 3 4 5 6 7 8 9 10 >10

5. Current Coverage Limits: Please Select 1,000,000/2,000,000 1,000,000/1,000,000 Other

6. Type of Coverage: Occurrence Claims Made

7. Has any policy or coverage being applied for been declined/non-renewed, or cancelled for non-payment within the last 3
     years? Yes No

8. Number of additional insured anticipated during policy period: Please Select 1-5 6-10 10 or More

9. Number of waiver of subrogation/special wording anticipated during policy period: Please Select 1-5 6-10 10 or More

10. Brief summary of your operations 25-30 words

 

		Enter $ Amount
11. Projected Annual Revenue for the next 12 months		$
12. Total Payroll		$
	Number of Owners (in the field)	#
	Total Field Payroll	$
	All Other Payroll	$

	New	Remodel
13. Percent of Total Revenue for Commercial Work?	%	%
14. Percent of Total Revenue for Industrial Work?	%	%
	Interior	Exterior
15. Percent of Total remodeling work	%	%

16. Previous sales past 12 months

17. Average premium per contract

18. Operations sold, discontinued or acquired last 5 years? Yes No

19. Number of additional insured endorsements estimated this year Please Select >1 2-5 6-10 11-15 15-20

20. Perform work/repairs on fire damage, water or mold? Yes No

	Yes	No
21. Do you hire subcontractors under standard written contracts? 21a. If yes, do the contracts contain standard hold harmless indemnification agreements in your favor?
22. Are updated certificates of insurance from subcontractors kept on file a minimum of 5 years?
23. Do you have a written Employee Health & Safety Plan?
24. Do you have at least 3 years of construction experience in the field of their current business/trade?
25. Do you have any open bankruptcies or tax or credit liens?
26. Have you performed or have future plans to perform Exterior insulation & finish system (EIFS) installation or repair?
27. Give a brief summary general liability losses in the last 3 years

28. Check all boxes that your have performed work on or plan to work on over the next 12 months
New Tract Homes
New Condo/Townhouses
New Apartments
Remodeled Apartments
WRAP/OCIP

SUB CONTRACTORS INFO

29. Total % of Work Sub-Contracted

30. Total Estimated Sub Costs: $

 

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COMMERCIAL AUTO

1. Current Carrier Name:

2. Date Policy Expires:

3. Number of years with current carrier Please Select 1 2 3 4 5 6 7 8 9 10 >10

4. Years of continuous coverage: Please Select 1 2 3 4 5 6 7 8 9 10 >10

5. Current Liability Limit: $1,000,000 $500,000 Other $

6. Current Uninsured/Underinsured Limit: $1,000,000 $500,000 Other $

7. Current Medical Please Select $5,000 $10,000 $15,000 $20,000 $25,000 Other $

	Yes	No
8. Do you have employees who use personal vehicles for work related duties?

9. If yes how many employees:

	Yes	No
10. Do these employees carry Personal Auto Insurance Policies for their vehicles?

Vehicle Information

**NOTE: To bypass completing the information on all vehicles email a copy of your current coverage and vehicle listing to nari@lawson-hawks.com

1. Limits of Liability: $1 Million CSL

2. Comprehensive and Collision:

No Coverage

$500 Deductible

$1000 Deductible

$2500 Deductible

$5000 Deductible

3. Uninsured/underinsured Motorist Coverage Amount Please Select $100,000 $300,000 $500,000 $1,000,000

Commercial Vehicle #1

Year of Vehicle Please Select 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 Make & Model

Type (truck, bobtail, etc.): Cost New: $

Driving Radius Please Select 0-25 mi 26-50 mi >50 mi

List special Equipment or modification & values (i.e., rack, toolbox, etc.)

VIN # (highly suggested for accurate rating)

Commercial Vehicle #2

Year of Vehicle Please Select 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 Make & Model

Type (truck, bobtail, etc.): Cost New: $

Driving Radius Please Select 0-25 mi 26-50 mi >50 mi

List special Equipment or modification & values (i.e., rack, toolbox, etc.)

VIN # (highly suggested for accurate rating)

Commercial Vehicle #3

Year of Vehicle Please Select 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 Make & Model

Type (truck, bobtail, etc.): Cost New: $

Driving Radius Please Select 0-25 mi 26-50 mi >50 mi

List special Equipment or modification & values (i.e., rack, toolbox, etc.)

VIN # (highly suggested for accurate rating)

Commercial Vehicle #4

Year of Vehicle Please Select 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 Make & Model

Type (truck, bobtail, etc.): Cost New: $

Driving Radius Please Select 0-25 mi 26-50 mi >50 mi

List special Equipment or modification & values (i.e., rack, toolbox, etc.)

VIN # (highly suggested for accurate rating)

Commercial Vehicle #5

Year of Vehicle Please Select 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 Make & Model

Type (truck, bobtail, etc.): Cost New: $

Driving Radius Please Select 0-25 mi 26-50 mi >50 mi

List special Equipment or modification & values (i.e., rack, toolbox, etc.)

VIN # (highly suggested for accurate rating)

 

Additional Vehicles

Provide Year/Make/Model/VIN for all additional vehicles on this policy Year/Make/Model/VIN#

Driver Information

**NOTE: To bypass completing the information for all Drivers email a copy of your current driver list to nari@lawson-hawks.com

DRIVER INFORMATION # 1

All information as it appears on License.

Driver Name Birthdate:Month Please Select January February March April May June July August September October November December Day Please Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year Please Select 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930

Issuing State License Number:

Remarks:

 

DRIVER INFORMATION # 2

All information as it appears on License.

Driver Name Birthdate:Month Please Select January February March April May June July August September October November December Day Please Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year Please Select 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930

Issuing State License Number:

Remarks:

DRIVER INFORMATION # 3

All information as it appears on License.

Driver Name Birthdate:Month Please Select January February March April May June July August September October November December Day Please Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year Please Select 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930

Issuing State License Number:

Remarks:

 

DRIVER INFORMATION #4

All information as it appears on License.

Driver Name Birthdate:Month Please Select January February March April May June July August September October November December Day Please Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year Please Select 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930

Issuing State License Number:

Remarks:

 

DRIVER INFORMATION #5

All information as it appears on License.

Driver Name Birthdate:Month Please Select January February March April May June July August September October November December Day Please Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year Please Select 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930

Issuing State License Number:

Remarks:

Number of claims within the last 5 years for all drivers?

Brief description of those exceeding $5000

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	Yes	No
Do you currently have a Drivers Selection Program in place?
Do you currently have a Driver Safety Policy/Program in place?

Certifying Receipt of Authorization to obtain driving records and/or consumers reports approval by client-insured.
Lawson-Hawks Insurance Associates has reviewed its obligations under the Fair Credit Reporting Act as a consumer report user, and certifies that it has received or will receive consumer reports, and certifies that it has received or will receive in advance of requesting information about the driving records of or consumer reports about any job applicant/employee, an authorization in which the applicant/employee authorizes the procurement of his/her consumer reports, including driving records, and the procurement of additional reports about him/her from time to time to evaluate his/her insurability or for other permissible purposes.
Insured will retain the job applicant’s/employee’s authorization on file in accordance with the requirements of the law for at least two years, and provide to the applicant/employee all required notices.

I approve Lawson-Hawks Insurance Associates to Obtain Driving Records on our employees
I do Not Approve

Insured Name and Title

Today's Date