NYSEC Application
Name of Business:
Address:
Contact Name and Phone Number:
Web Site:
Email Address:
Property Information:
(Provide for Each Location Insured)
Location 1
Location 2
Location 3
Location Address:
Building Limit:
Contents Limit:
Construction Type:
Square Footage:
Year Built:
Year of Remodeling:
Other Occupancies:
*
Inland Marine
Please list a schedule of equipment you'd like to insure:
How many jobs a year do you do?
Commercial:
Residential:
What is the job size: Smallest: $
Largest: $
*General Liability: Policy Effective Date
mm/dd/yyyy
1. What type of electrical work do you do?
2. Total Gross Annual Sales: $
3. What is your total Field Payroll (not clerical or sales people):
Break it down as follows:
Wiring of Buildings:
Street or Traffic Lights:
Machinery:
Interior of offices for computers and phones:
Fire or Burglar Alarms:
Other:
Do you Use Subs?
If so, what do they do?
Total w/ annual cost of subs:
Who supervises the subs on the jobsite, and how often does that occur?
Do you require certificates of insurance from all subs?
CGL Limits required:
Occurrence:
$
Aggregate:
$
Do you require subs to sign written construction contracts containing indemnity / hold harmless clauses in your favor?
Do you monitor subs to make sure that they are in standard markets that provide full GL coverage including contractual liability?
*Automobile: Policy Effective Date
mm/dd/yyyy
From your current policy, list the schedules of automobiles to insure. It should include VIN #’s, comprehensive and collision deductibles, etc.
*Umbrella: Policy Effective Date
mm/dd/yyyy
What limit would you like us to quote?
