Mortgage Field Services Insurance Application Form One Simple Form - takes only 2-3 Minutes! FOR FAST QUOTES - Answer ALL QUESTIONS! If a question does not apply to You or Your job, please answer DNA (does not apply) Be specific about Job/Work performance Minimum Premium for Program is $1,000.00 Plus Fees - Please Keep this in Mind. NOT FOLLOWING THESE INSTRUCTIONS WILL ONLY DELAY YOUR QUOTE FOR 72 HOURS OR LONGER
Your Name:
BUSINESS Name:
Mailing Address:
City:
State:
Zip/Postal:
Company Web Site Address:
E-Mail (REQUIRED):
Phone:
Fax (optional):
Business Underwriting Information
State of operation:
Years in Business:
Effective Date of Coverage Requested:
Gross Receipts:	$
Subcontracted Costs:	$
Gross Payroll:	$
Payroll/Sales Description |    Payroll   | Sales Glass Dealers and Glaziers [13590] Locksmiths [14913] Pest Control Services [43470] Real Estate Property Managed [47052] Carpentry - 3 Stories or Less [91342] Drywall or Wallboard Installation [92338] Engineers or Architects [92663] Inspection or Appraisal Company [96317] Janitorial Services [96816] Lawn Care Services [97050] Plumbing, Residential [98483] Roofing, Residential [98678] Snow & Ice Removal [99310] Truckers / Movers [99793] Other (Detail in Remarks) Other (Detail in Remarks) Other (Detail in Remarks)
Retro Date:
Professional Desired?	Yes No
Provide a detailed description of your operations:
1. Are You a Safeguard Contractor?	Yes No
	If yes, for how long?
2. Are You a Licensed Contractor?	Yes No
3. Is there a Safety Program in Place?	Yes No
4. Do you currenlty comply with Safeguard Program Requirements?	Yes No
5. Do you perform work outside the Safeguard Program?	Yes No
If yes, do you have     GL Coverage Elsewhere?	Yes No
Provide Insurance Carrier Name, Policy Term and Limits:
6. Have you Ever Had your General Liability and/or Professional Liability coverage cancelled or non-renewed?	Yes No
If Yes, provide details:
7. Do you have any discontinued operations/exposures not disclosed in the application?	Yes No
8. Have you experienced any losses greater than $10,000 in the past 5 years?	Yes No
If Yes, provide details in numerical order FOR EACH CLAIM as follows: 1) Date of Loss 2) Total Loss Incurred 3) Description of Claim 4) Status of Claim (open/closed) 5) Valuation Date
9a. Have you experienced more than 5 claims per year during any of the past 5 years?	Yes No
9b. List details of ALL CLAIMS in past 5 years: On claims in past 5 years, provide details in numerical order FOR EACH CLAIM as follows: 1) Date of Loss 2) Number of Claims 3) Paid Losses 4) Expenses Paid 5) Total Reserve 6) Total Loss Incurred 7) Valuation Date 8) Insurance Carrier Name
10. Have you ever had a construction defect claim?	Yes No
11. Do you ever utilize sub-contractors?	Yes No
If Yes, do you require subcontractor to carry insurance limits equal to, or greater than yours?	Yes No
If yes, do you require Certificates of insurarance, AI status and favorable hold harmless agreements?	Yes No
12. Has Current Management Been in Place over 2 years?	Yes No
13. Has Payroll or Gross Receipts grown over 20% in past 3 years?	Yes No
14. Do You employ any leased or temporary workers?	Yes No
15. Do You perform any work over 3 stories?	Yes No
16. Have you ever been involved with new construction?	Yes No
17. Do you perform and environmental remediation (including but not limited to mold, asbestos, or lead?	Yes No
18. Do you remove any hazardous waste?	Yes No
19. Do you preserve properties valued at over $2 Million?	Yes No
20. Describe any other exposures not previously addressed:
21. Detail Jobsite Security:
22. Describe Losses, # of claims, Paid losses, and reserves, and insurance carrier if you have had claims:
23. Describe Any Losses Greater than $10,000:
Limit of Liability Coverage Requested?	$300,000 $500,000 $1 Million $2 Million +

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