Guardian Application - USIC-CMGIA 04-2012 - Insurance policy application form

Sep 15, 2026

Uploaded by Fez

Insurance policy application form for United Specialty Insurance Company collecting applicant and producer details, coverage effective/expiration dates, entity type, operating history, years of experience, and physical address if different. Requires states where work will be performed, business description, contractor license information, and prior carrier data for the past three years including losses. Collects claims-precondition disclosures, coverage requested and limits, general contractor/subcontracting questions, planned gross receipts, current largest jobs, work-percentage allocation, and past or upcoming specialty work selections.

LanguageEnglish

CategoryForms

FormatPDF

Pages4

Reading Time2 min

AccessFree to download

Applicant Information

Coverage Requested

Operations and Loss History

Contractors, Receipts, and Work Details

UNITED SPECIALTY INSURANCE COMPANY The words “Applicant”,“You” or “Your” refer to the person or entity applying for the insurance policy. Producer Information: Applicant Information: | Name: | | Name: | | | --- | --- | --- | --- | | Contact: | | DBA: | | | Address: | | Address | | | E-Mail Address: | | E-Mail Address: | | | Phone: | Fax: | Phone: | Fax: | | Producer Code: | | FEIN\#: | | | Affiliated Associations: | | Inspection Contact: | | Provide Your Physical Address if Different from The Address Listed Above: Desired Effective Date of Coverage: Expiration Date of Current Coverage: Entity Type: 􀂆 Individual 􀂆 Partnership 􀂆 Joint Venture 􀂆 Corporation 􀂆 LLC 􀂆 Other: Years Applicant Has Been in Operation: (If The Applicant Has Been in Business Less Than 2 Years, Provide Detailed Resumes ofAll Owners, Officers, Members or Partners.) Years of Experience: List All States which work will be performed in during the policy period: Provide Detailed Description of Your Business, Operations and Services: __________ List All Contractor Licenses Held By Applicant in Each State or County or Provide a Current Copy of Each License | License Number | State License is Held | | --- | --- | | | | | | | | | | Prior Carrier Information For The Applicant For The Past 3 Years: | Carrier Name | Effective Dates of Coverage | Limits | Premium Paid | Number And Amount of Losses | | --- | --- | --- | --- | --- | | | | | | | | | | | | | | | | | | | Please Note: A Current Valued Loss Run and/or a No Known Loss Letter, Signed and Dated by The Applicant, is Required. Please Provide Specific Details on All Past Losses: Have You Owned and/or Operated Any Other Business, Contracting or Otherwise, in the Past 5 Years? 􀂆 Yes 􀂆 No If Yes, State Your Percentage of Ownership: Provide a Detailed Description of The Operations: Are You Aware of Any Litigation, Past or Pending Against You The Applicant or Your Business in the Past 5 Years: 􀂆 Yes 􀂆 No If “Yes”, Explain in Detail: Do You Have Any Knowledge of Any Occurrence, Condition, Act, Omission, Event, Harm or Damages to Any Person or Property that May Potentially Give Rise to Any Future Claim or Legal Action Against The Applicant? 􀂆 Yes 􀂆 No If “Yes”, Explain in Detail: USIC-CMGIA 04-2012 Page 1 of 4 | Coverage Requested: | S.I.R.: | Limits: | | | --- | --- | --- | --- | | Manuscript Occurrence – Endorsement(s)
􀀀 Primary Wording
􀀀 Waiver of Subrogation
􀀀 Alien 20 10 11 85
􀀀 Additional Fire Coverage
􀀀 Snow Plow (only available to Insured with Commercial Auto Policy)
􀀀 Blanket Additional Insured-Company Form
􀀀 Additional Insured
􀀀 Stop Gap Coverage | 􀂆 $2,500
􀂆 $5,000
􀂆 $7,500
􀂆 $10,000
􀂆 $ | General Aggregate
Products-Completed Operations Aggregate
Personal & Advertising Injury Each Occurrence
Fire Damage (Any One Fire)
Medical Expenses (Any One Person) | $
$
$
$
$50,000
$ 5,000 | A) . Are you a General Contractor? 􀂆 YES 􀂆 NO B) . Do you subcontract out 100% of your work? 􀂆 YES 􀂆 NO C) . If you do not subcontract out all of your work, please list the trades you will perform during the next 12 months and their dollar value: _______________________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________ Your Gross Receipts Next 12 Months: $ Your Actual Gross Receipts Current Year: $ Your Actual Gross Receipts Prior Year: $ Current &/or Planned Work. Please List your 3 Largest Jobs Currently in Progress or with Planned Start Dates in the Next 12 Months: | Project Name & Address | Project Type | Work Performed | Anticipated Gross Receipts | | --- | --- | --- | --- | | | | | | | | | | | | | | | | Perc

FAQs

What applicant details are requested in the form?

The form requests applicant name, contact information, DBA, address, email, phone/fax, producer code, affiliated associations, inspection contact, and physical address if different.

What prior information about losses and carriers is required?

It asks for prior carrier information for the past three years (coverage effective dates, limits, premiums paid, and number/amount of losses) and specific details on past losses, including a current valued loss run and/or no known loss letter signed and dated by the applicant.

What questions address contracting structure and upcoming work?

It asks whether the applicant is a general contractor, whether 100% of work is subcontracted, lists trades with dollar values if not fully subcontracted, and requests gross receipts plus the three largest jobs planned or in progress in the next 12 months.

Sep 15, 2026

Uploaded by Fez