Form A 60 – Fill Out and Use This PDF

Member companies of Western World Insurance Group

Attach a complete list of name insureds including a brief description of each.

If any work as a Project Manager, Developer, or Construction Manager please describe:

If any work as a Project or Construction Manager does applicant carry an E & O policy?

4.Area of operations (county/state):

What Workers Compensation requirements do you require of your subcontractors? ________________

___________________________________________________________________________________

7.Receipts expected during coming policy period: $

8.Payroll of active owners (except those exclusively in clerical or sales): $

9.Number of employees (including leased) in the following classes:

Provide a list of trades performed by the named insured:

10.Annual subcontracted cost (labor and material): $

(Include cost of all material provided by you, a sub, an owner or a bank.)

11.Does applicant normally employ the same subcontractors?

Provide a list of major subcontractors used. (Attach page if more space is needed.)

How long are they kept? _______________________________________________

Explain any “No” responses to quest #12. _______________________________________________________

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Attach sample copy of agreements with subcontractors (subcontractor agreements, additional insured’s and their interest and any hold harmless wording).

13.Show percent of work performed in: (each row should equal 100%)

16.Have you built, are you building or remodeling any condominiums, town houses or tract homes? If so, describe

Number of residential homes anticipated to be constructed over the next year? ________

17.Indicate the number of residential homes or condos built over the past three (3) years. Indicate the number of condos remodeled in the past three (3) years.

Describe work done in detail (attach separate sheets if needed)

28.Loss History for the past five (5) years: (Please include currently valued, company issued loss runs)

1.

2.

3.

4.

5.

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30.Expiring Carrier Information (past five (5) years):

1.

2.

3.

4.

5.

31.Loss Control:

A.Does the applicant test all land, even if partially developed, before purchasing for development? ______ Or, does the applicant only rely on the soils tests supplied by the seller?

B.Does the applicant have a soil engineer on staff?

________________________________________________

If not, is an independent soil engineer contracted?_______________________________________________

Does the soil engineer hold the applicant harmless and name it as an additional insured? _______________

C.Does the applicant employ an independent inspector that inspects each phase of construction?

_______________________________________________________________________________________

If so, what is the name of the inspection company/companies?

D.During the past three (3) years, has any company ever cancelled, declined, or refused to issue similar insurance to the applicant? _____________ If yes, please provide details:

32.Management/Quality Control:

1. Please attach a copy of the applicant’s quality control program.

2. What is your construction experience and that of your key personnel? (attach resume(s), if available):

3.Who in the applicant’s organization is responsible for customer service?

4.How long does the applicant respond to complaints? __________________________________________

5.Would the applicant respond to homebuyers’ complaints after their warranty periods? ________________

6.If so, what is the maximum time the applicant would do this? _____________________________________

7.Please describe the process by which the applicant handles homebuyer’s complaints, including documentation and follow-up with the homebuyer. Include a description of the applicant’s process when a subcontractor is needed for repairs. Please include the follow-up procedure after the repairs have been made:

8.Does the applicant provide a homeowners manual which describes maintenance schedules and proper use of property to all homebuyers?

9.Are homeowner’s warranty policies provided to homebuyers? ______________________________________

10. Please attach a sample homeowner warranty policy.

Applicant agrees to notify the Company of any material changes in the answers to the questions on this application which may arise prior to the effective date of any policy issued pursuant to this Application and the Applicant understands that any outstanding quotations may be modified or withdrawn based upon such changes at the sole discretion of the Company.

Notwithstanding any of the foregoing, the applicant understands the Company is not obligated nor under any duty to issue a policy of insurance based upon this Application. The Applicant further understands that, if a policy is issued, this Application will be incorporated into and forms a part of such policy.

Signature of Applicant:

Date:

Title (Officer, Partner):