NYSEC Application NEW YORK STATE ASSOCIATION OF ELECTRICAL CONTRACTORS INSURANCE PROGRAM APPLICATION Step 1 of 5 20% Name * RequiredName of Business:PhoneEmail Address: * RequiredAddress:Web Site:Years in Business:mm/dd/yyyy Property Information: (Provide for Each Location Insured)Policy Effective Datemm/dd/yyyyLocation 1Location Address:Building Limit:Construction Type:Contents Limit:Square Footage:Year Built:Year of Remodeling:Other Occupancies:Location 2Location Address:Building Limit:Contents Limit:Construction Type:Square Footage:Year Built:Year of Remodeling:Other Occupancies:Location 3Location Address:Building Limit:Contents Limit:Construction Type:Square Footage:Year Built:Year of Remodeling:Other Occupancies:*Inland MarinePolicy Effective Datemm/dd/yyyyPlease 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 Datemm/dd/yyyy1. 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?*AutomobilePolicy Effective Datemm/dd/yyyyFrom your current policy, list the schedules of automobiles to insure. It should include VIN #’s, comprehensive and collision deductibles, etc.*Umbrella:Policy Effective Datemm/dd/yyyyWhat limit would you like us to quote?4 years of loss history will be required prior to binding coverage.PhoneThis field is for validation purposes and should be left unchanged.