Quote 181022 Chim Chimney Sweeps, LLC. 503-724-2299 Cover Page and Binding Instructions Insurance Carrier: AMTrust International Underwriters Ltd. (760) 345-9029 Underwriter: Retail Brokerage: West Coast Insurance Brokers, Inc. 503-268-7432 Broker / Rep: Sophia Adams STEP 1 - Review, Sign, and Collect requirements Signed Application Signed Endorsements (if selected) Signed No Loss Letter Signed Finance Agreement Payment in the amount of: $1,457.43 STEP 2 - Upload, Email, or Fax request to (760) 345-9028 Upload or email signed copy to your underwriter Underwriter will review your submission and bind STEP 3 - Policy issued via email Policy will be emailed to: [email protected]STEP 4 - Payment Options STEP 5 - Send SCIS Check Authorization form for amount due at time of binding. PAY-IN-FULL $1,457.43 LOW-DOWN PFA $291.49 3RD PARTY PFA $657.43
Transcript
Quote 181022
Chim Chimney Sweeps, LLC.503-724-2299
Cover Page and Binding Instructions
Insurance Carrier: AMTrust International Underwriters Ltd. (760) 345-9029Underwriter:
Retail Brokerage: West Coast Insurance Brokers, Inc. 503-268-7432Broker / Rep: Sophia Adams
STEP 1 - Review, Sign, and Collect requirementsSigned ApplicationSigned Endorsements (if selected)Signed No Loss LetterSigned Finance AgreementPayment in the amount of: $1,457.43
STEP 2 - Upload, Email, or Fax request to (760) 345-9028Upload or email signed copy to your underwriter
Underwriter will review your submission and bind
STEP 3 - Policy issued via emailPolicy will be emailed to: [email protected]
STEP 4 - Payment Options
STEP 5 - Send SCIS Check Authorization form for amount due at time of binding.
PAY-IN-FULL $1,457.43 LOW-DOWN PFA $291.49 3RD PARTY PFA $657.43
Quote 181022
Chim Chimney Sweeps, LLC.503-724-2299
Coverage - Pricing - Payment Information
PRICING IS VALID FOR 30 DAYS FROM: 3/7/2017COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE LIMIT $1,000,000GENERAL AGGREGATE LIMIT $2,000,000HOT TAR & TORCHDOWN $100,000 SUBLIMITFIRE CAUSED BY HEATING DEVICE $100,000 SUBLIMITPRODUCTS/COMPLETED OPERATIONS $2,000,000PERSONAL & ADVERTISING INJURY $1,000,000FIRE LEGAL LIABILITY $50,000MEDICAL PAYMENT LIMIT $5,000
DEFENSE EXPENSES AS THE TERM IS DEFINED IN THE POLICY ARE INCLUDED WITHIN THEINDEMNITY LIMITS AS DEFINED IN THE POLICY
PRICING INFORMATIONPREMIUM $1,000.00POLICY FEES $410.00ENDORSEMENTS $0.00Surplus Lines Service Charge $15.00OR Surplus Lines Tax $28.20OR Fire Marshall Tax $4.23
TOTAL: $1,457.43
DOWN PAYMENT, TAX & FEES DUE WITHIN 10 DAYS OF EFFECTIVE DATE OR CANCELLATION NOTICE WILL BE SENT.
Quote 181022
Chim Chimney Sweeps, LLC.503-724-2299
Endorsements Selected
Please note these endorsements were selected for this policy at bind.
Endorsement Name Form #SCIS-CGL-DEC1Declarations PageSCIS-CGL-DEC2Supplemental Declarations PageSCIS-CGL-SCHSchedule of Forms and EndorsementsAIUL SIGNATURE PAGEUSI Signature PageCPS33002Service of SuitIL 00 21 09 08Nuclear Energy Liability Exclusion EndorsementCG 21 84 01 08Exclusion of Certified Nuclear, Biological, Chemical or Radiological Acts of TerrorismCG 21 70 01 08Cap on Losses from Certified Acts of TerrorismSCIS-BIP-1Bodily Injury on Property Owned by InsuredShieldSEGLState and Foreign Operations Exclusion and Governing LawSCIS-BAI-3Blanket Additional Insured EndorsementSCIS-CGLCommercial General Liability Coverage Form
ADDITIONAL ENDORSEMENTS ARE AVAILABLE, CONTACT YOUR UNDERWRITER FOR MORE DETAILS.
INSURED'S INFORMATIONEffective Date: 3/31/2017Applicant: Chim Chimney Sweeps, LLC.Contact: Tyler J HauxwellPhysical Address: 84402 Joseph HwyCity, St Zip Enterprise, OR 97828Mailing Address: PO BOX 92Mailing City, St Zip Enterprise, OR 97828Telephone / Fax: 503-724-2299Email Address: [email protected]'s license #: 202616Business Type: LLC
WORK EXPERIENCE:States in which you do business: ORYears in business for yourself: 3Years in profession: 13Detail Description of Operation:
Insured does residentail chimney cleaning.
EXPOSURES:a. Gross Receipts for the next 12 months? $50,000b. What are the Gross Receipts for the last 12 months? $50,000c. What are your "Insured" subcontractor costs for the next 12 months? $0d. What is payroll for the next 12 months? $20,000e. Number of field employees? 1
WORK EXPERIENCE:Percentage of work Performed:
Residential Commercial New Tract Remodel/Repair/Service100 0 0 0 100
Describe in detail your largest project in the last 5 years along with the receipts $$$. (DETAIL REQUIRED BY CARRIERFOR APPROVAL):
Residential chimney sweeping $3,000
Have you been involved or do you subcontract any work involving blasting operations,hazardous waste, asbestos, mold, PCB's or medical and/or industrial life? Yes No
WORK EXPERIENCE: (continued)Do you use subcontractors? Yes NoDo you do any work for condominium or townhouse associations? Yes NoDo you do OCIP (Wrap-up) work? Yes NoAny work performed for a fee or with labor and/or material costs paid by others? Yes NoHave you allowed or will you allow your license to be used by any other contractor? Yes NoHas any lawsuit ever been filed, or any claim otherwise been made against yourcompany of any partnership or joint venture of which you have been a member of yourcompany's predecessors in business, or against any person, company or entities onwhose behalf your company has assumed liability?
Yes No
Is your company aware of any facts, circumstances, incidents, situations, damages oraccidents (including but not limited to: faulty or defective workmanship, product failure,construction dispute, property damage or construction worker injury) that a reasonablyprudent person might expect to give rise to a claim or lawsuit, whether valid or not, whichmight directly or indirectly involve the company?
SUPPLEMENTAL QUESTIONS: (work in progress)Yes NoDo you have a project in progress for which you are seeking coverage under this application?
SUPPLEMENTAL QUESTIONS: (litigation against applicant's)Within the past 4 years have you filed any lawsuits and/or arbitration actions against any ofyour customers for nonpayment of your services and/or materials you supplied?
The policy you are applying for is issued by a Surplus Lines Carrier. The Surplus Lines Carrier may not besubject to all of the insurance laws and regulations of your State. State insurance insolvency guaranty funds arenot available for a Surplus Lines Carrier.
The Applicant acknowledges that Applicant has read or has had the opportunity to read a sample of the Policy form thatwill be issued to the Applicant as well as commonly used endorsements. The Applicant further acknowledges that thesample may not contain all of the endorsements, restrictions that may be ultimately issued to the Applicant. The Applicantfurther acknowledges that a copy of the Policy form and commonly used endorsements has been made available toApplicant’s broker. Further the Applicant acknowledges that a copy of the Contractors Shield Policy form and commonlyused endorsements are available for review by either the Applicant or the Applicant’s broker by contacting ShieldCommercial Insurance Services at 760-345-9029x223 or
Applicant’s Initials:
THERE ARE EXCLUSIONS, RESTRICTIONS, SUBLIMITS AND CONDITIONS IN THE POLICY THAT LIMITCOVERAGE. SOME, BUT NOT ALL OF THESE ARE TITLED AS FOLLOWS:.
b DEFENSE COSTS REDUCE INDEMNITY LIMITSb BINDING ARBITRATION CLAUSEb SELF INSURED RETENTIONb TORCH AND HOT TAR SUBLIMIT OF $100,000
○ Applicant confirms that a 2 hour fire watch is required for sub limit coverageb HEATING DEVICE SUBLIMIT OF $100,000b SOME OF THE EXCLUSIONS
○ SUB-CONTRACTOR RELATED CLAIMS UNLESS INDEMNITEE AGREEMENTS, CERTIFICATES EVIDENCING QUALOR GREATER LIMITS AND ADDITIONAL INSURED STATUS ARE OBTAINED PRIOR TO COMMENCEMENT OFWORK
○ OPEN ROOF WATER DAMAGE EXCLUSION○ TOTAL POLLUTION○ VARIOUS MATERIAL, BIOLOGIC AND RADIATION EXCLUSIONS: ASBESTOS; CHROMATER COPPER ARSENATE;
CONCRETE SULFATES; ELECTROMAGNETIC RADIATION; LEAD; MOLD; BACTERIA AND OTHER ORGANICALLY-CAUSED DAMAGES; CHINESE DRYWALL AND OTHER IMPORTED BUILDING MATERIALS; FIBERGLASS;FORMALDEHYDE; ARSENIC; FIRE RETARDANT TREATED PLYWOOD; ENTRAN PIPE; CCA WOODPRESERVATIVES; AIRBORNE MANGANESE; DIOXIN; SILICA; MIXED DUST; POLYCHLORINATED BIPHENYLS;TRANSMISSIBLE SPONGIFORM ENCEPHALOPATHY; COMMUNICABLE DISEASE
○ EARTH MOVEMENT○ BLASTING OPERATIONS○ LIABILIITY TO EMPLOYEES (ACTION OVER)○ EXTERIOR INSULATION AND FINISH SYSTEMS (E.I.F.S)○ PAST PROJECTS/PRIOR WORK (Unless in continuous and unbroken renewal under the policy)○ JOBS IN PROGRESS REQUIRE ENDORSEMENT○ CONDOMINIUM AND TOWNHOUSE EXCLUSION EXCEPT FOR REPAIR TO INDIVIDUAL UNIT FOR UNIT OWNER○ WRAP-UP/OCIP○ EXCAVATION FOR OTHER THAN SINGLE FAMILY HOUSING, AND EXCAVATION OVER 8'○ FOUNDATION REPAIR○ GREEN BUILDING○ MULTIFAMILY DWELLINGS IN EXCESS OF 15 UNITS○ TRACTS IN EXCESS OF 15 HOMES○ NON-COMPLIANCE WITH BUILDING CODES○ UNLICENSED WORK○ PROFESSIONAL LIABILITY○ TERMINATION OF COVERAGE FOR FAILURE TO PAY OR COOPERATE WITH AUDIT
The Applicant further acknowledges the Policy has other restrictions in coverages.
The Applicant authorizes the Broker to sign on behalf of the Applicant any documents modifying the terms and conditionsof the policy including but not limiting to the purchase of additional endorsements, changes in coverage including policylimits, and the execution of any documents necessary to obtain a renewal and/or extension of the policy.
Applicant’s Initials:
The Applicant warrants that after inquiry, no one employed by or associated with Applicant is aware of any complaints,allegations, demand for payment of money or the performance of services, claims, incidents, potential claims, acts, errors,omissions, facts, circumstances, situations, events or transactions that could reasonably result in a claim or lawsuit beingpresented against Applicant or anyone employed by or associated with Applicant
The Applicant warrants that the above statements and particulars, together with any attached or appended documents ormaterials (this application), are true and complete, and do not misrepresent misstate, or omit any material facts.Furthermore, the Applicant authorizes SCIS as administrative and servicing manager, to make any investigation andinquiry in conjunction with the application as it may deem necessary. The Applicant agrees to notify SCIS of any materialchanges in the answers to the questions on this application which may arise prior to the effective date of our Policy issuedin pursuant to this application and the Applicant understands that any outstanding quotations may be modified orwithdrawn based upon such changes at the sole discretion of SCIS.
The Applicant further understands that, if a Policy is issued, this Application will be incorporated into and form a part ofsuch Policy and any false information provided in this application will result in nullification of the Policy. The Applicantunderstands that information contained herein is specifically relied upon by SCIS in the issuance of the Policy. Theundersigned, therefore, warrants that the information contained herein is true and correct. The Applicant understands thatmisrepresentation or omission shall constitute grounds for either an early cancellation or denial of coverage of claims, ifany. It is understood that the Applicant and or affiliated companies are under a continuing obligation to immediately notifySCIS of any material alteration of the information given. The Applicant also acknowledges, that the Applicant has notsustained a loss nor has any claim been made against the Applicant within the last 5 years unless otherwise disclosed inthis application.
Applicant’s Initials:
The Applicant understands that if the Applicant utilizes the premium finance arrangement provided through SCIS theprogram & filing fees, inspection fee and agency fee will be fully earned and Applicant is responsible for and will guarantythose payments.
Notwithstanding any of the foregoing, the Applicant understands SCIS is not obligated nor under any duty toissue a Policy of insurance based upon this application. SCIS is relying on the statements in issuing the policy.The Applicant's statements are material and truthful. The applicant is signing this statement under penalty ofperjury.
NOTICE: In some states, any person who knowingly, and with the intent to defraud any insurance company or otherperson, files an application for insurance or statement of claim containing any materially false information, or, for thepurpose of misleading, conceals information concerning any fact material thereto, may commit a fraudulent insuranceact which is a crime in many states.
Please bind per quote with the effective date of 3/31/2017
Date:__________________
Signature of Applicant:_________________________________________
Title (Owner, Office, Partner):___________________________________________________
UCISG Notice of Terrorism
NOTICE OF TERRORISM INSURANCE COVERAGE
I
You are hereby notified that under the federal Terrorism Risk Insurance Act, as amended ("the Act"), the Company
must make available insurance coverage for losses arising out of acts of terrorism, as defined in Section 102(1) of
the Act. This policy includes such coverage for damages arising out of certified acts of terrorism and is limited by
the terms, conditions, exclusions, limits, other provisions of the coverage quote or renewal
application/questionnaire to which this offer is attached and by the policy, any endorsements to the policy and
The term "act of terrorism" means any act that is certified by the Secretary of the Treasury, in concurrence with the
Secretary of State, and the Attorney General of the United States to be an act of terrorism; to be a violent act or an
act that is dangerous to human life, property, or infrastructure; to have resulted in damage within the United States,
or outside the United States in the case of an air carrier or vessel or the premises of a United States mission; and to
have been committed by an individual or individuals as part of an effort to coerce the civilian population of the
United States or to influence the policy or affect the conduct of the United States Government by coercion.
YOU SHOULD KNOW THAT COVERAGE PROVIDED BY THIS POLICY FOR LOSSES RESULTING
FROM CERTIFIED ACTS OF TERRORISM, SUCH LOSSES MAY BE PARTIALLY REIMBURSED BY
THE UNITED STATES GOVERNMENT UNDER A FORMULA ESTABLISHED BY FEDERAL LAW.
UNDER THE FORMULA, THE UNITED STATES GOVERNMENT GENERALLY REIMBURSES 85% OF
COVERED TERRORISM LOSSES EXCEEDING THE STATUTORILY ESTABLISHED DEDUCTIBLE
NO PREMIUM IS CHARGED FOR THIS COVERAGE NOR IS ANY CHARGE MADE FOR THE
PORTION OF LOSS THAT MAY BE COVERED BY THE FEDERAL GOVERNMENT UNDER THE
YOU SHOULD ALSO KNOW THAT THE ACT, AS AMENDED, CONTAINS A $100 BILLION CAP THAT LIMITS U.S
GOVERNMENT REIMBURSEMENT, AS WELL AS INSURERS' LIABILITY FOR LOSSES, RESULTING FROM
CERTIFIED "ACTS OF TERRORISM" WHEN THE AMOUNT OF SUCH LOSSES IN ANY ONE CALENDAR YEAR
EXCEEDS $100 BILLION. IF THE AGGREGATE INSURED LOSSES FOR ALL INSURERS EXCEED $100 BILLION,
YOUR COVERAGE MAY BE REDUCED.
COVERAGE FOR "INSURED LOSSES" AS DEFINED IN THE ACT IS SUBJECT TO THE COVERAGE
TERMS, CONDITIONS, AMOUNTS AND LIMITS IN THIS POLICY APPLICABLE TO LOSSES ARISING
FROM EVENTS OTHER THAN "ACTS OF TERRORISM".
DI L I GE NT S E A R C H S T AT EM E N T
To: Insurance Commissioner, State of Oregon
Insured Name:
Policy Number:
Policy Inception Date:
Policy Expiration Date:
Type of Coverage Provided:
I have determined that, as per the definition as stated in the federal Nonadmitted and Reinsurance Reform Act of 2010
Sec. 527, Oregon is the “home state” for this policy. (A copy of the federal Nonadmitted and Reinsurance Reform Act of 2010
can be viewed online at www.OregonSLA.org under “Publications”).
The Insured was expressly advised prior to placement of this insurance in the SURPLUS LINE MARKET that:
A. The Surplus Lines insurer with whom the insurance was placed is not licensed in this state and
is not subject to its supervision.
B. In the event of the insolvency of the SURPLUS LINES insurer, losses will not be paid by the
STATE INSURANCE GUARANTY FUND.
Select (check) Statement 1, Statement 2, OR Statement 3:
Statement 1:
I hereby certify that I have made a diligent effort to place this insurance with companies admitted to write business in Oregon
for this class. I am unable to place the full amount or kind of insurance with companies admitted to transact and who are
actually writing the particular kind and class of insurance in this state. I am therefore placing this insurance in the SURPLUS
LINE MARKET.
Statement 2:
I have determined that the insured is currently registered with Oregon as a Risk Purchasing Group (RPG), to purchase
liability insurance on a group basis, and that this policy placement is exempt from the Diligent Search requirement.
Statement 3:
I have determined that, as per the definition as stated in the Nonadmitted and Reinsurance Reform Act of 2010 Sec. 527, this
insured is an exempt commercial purchaser, that the requirements as set forth in the federal Nonadmitted and Reinsurance
Reform Act of 2010 Sec. 525 have been complied with, and that this policy placement is exempt from the Diligent Search
requirement. (A copy of the federal Nonadmitted and Reinsurance Reform Act of 2010 can be viewed online at
Chim Chimney Sweeps, LLC.PO BOX 92Enterprise, OR 97828
Loss Warranty Letter
During the last five (5) years, we warrant that with respect to the insurance being applied for:
1. I/We have not sustained a loss,2. I/We have not had a claim made against us,3. I/We have no knowledge or a reason to anticipate a claim or loss.
If my business is less than five (5) years old, the above referenced warranty applies to workperformed through all my prior business entities whether as an owner or an employee.
I understand that this warranty will be incorporated into the insurance contract.
Chim Chimney Sweeps, LLC.DBA Date
Signature of Partner, Officer, Principal or Owner Title
Warranty: The purpose of this no loss letter is to assist in the underwriting process.Information contained herein is specifically relied upon in determination of insurability. Thisletter warrants that the information contained herein is true and accurate to the best of his/herknowledge and belief. This no loss letter shall be the basis of any insurance that may beissued and will be a part of such policy. It is understood that any misrepresentation oromission shall constitute grounds for immediate cancellation of coverage or rescission ofpolicy and denial of claims, if any. It is further understood that the applicant and or affiliatedcompany is under a continuing obligation to immediately notify his/her underwriter throughhis/her broker of any material alteration of the information given.
All loan amounts under $1,000 will be subject to a $10
payment processing fee, which will be added to the
payment shown on the monthly invoce.
Originated by MW Premium Finance Corp. Lic. #2126 Serviced by PREMCO FINANCIAL CORPORATION P.O. BOX 19367 KALAMAZOO, MI 49019-0367 Phone (269) 375-3936 fax (269) 375-6913 LENDING DISCLOSURE
Premco Financial Corp.
COMMERCIAL
1,457.43
291.49
1,165.94
1,165.94
117.10
1,283.04
23.5%
West Coast Insurance Brokers, Inc.11834 SW Windmill DriveBeaverton, OR 97008503-268-7432
Chim Chimney Sweeps, LLC.PO BOX 92Enterprise, OR 97828503-724-2299
142.56 4/30/2017 31 9
3/31/2017AMTrust International Underwriters Ltd.Administered by:Shield Commercial Insurance Services, Inc.
GL 121,000.00
Fee: 410.00Tax: 47.43
Broker Fee: 0.00TOTAL: 1,457.43
Chim Chimney Sweeps, LLC.
P REMCO FINANCIAL CORPORATION
(269) 375-3936 ph• (269) 375-6913 fax po
box 19367• kalamazoo, mi 49019-0367
www.go-premco.com
EFT AUTHORIZATION AGREEMENT Account Information: You are the Agent the Insured
Name: PREMCO Loan / Quote #:
Address:
I (we) hereby make, constitute, appoint and authorize Premco Financial Corporation, hereinafter called COMPANY, as my/our true and lawful attorney to charge to my/our account at the financial institution named below, hereinafter-called DEPOSITORY, and to credit the same to my account with COMPANY. I/We acknowledge that charges to my/our account will occur in accordance with my/our Loan / Quote# as indicated above (and subsequent accounts) and may be adjusted or corrected for events including but not limited to endorsements, administrative error, and/or insufficient funds until my/our account balance is paid in full.
Bank Account Information
Bank Name: City: State:
Routing # Account # Type: □Checking □Savings
This Power of Attorney and authorization is to remain in full force and effect for this account and all of my/our subsequent accounts until COMPANY has received written notification from me (us) of its termination in such time and in such manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it, but in no event will occur later than three business days prior to the scheduled date of transaction. I/We further understand that sufficient funds must be available at the time each transfer is processed. In the event that there are insufficient funds, Premco will charge up to the maximum NSF fee permitted by law. If this authorization is for a Corporation or LLC, the undersigned is an officer of said Corporation or a member of the LLC and authorized to execute this authorization on behalf of the Corporation or LLC.
Tape a voided check (checking) or deposit slip (savings) here. Please verify that the account and routing transit numbers are correct.
NOTE: ALL WRITTEN DEBIT AUTHORIZATIONS MUST PROVIDE THAT THE RECEIVER MAY REVOKE THE AUTHORIZATION ONLY BY NOTIFYING THE ORIGINATOR IN THE MANNER SPECIFIED IN THE AUTHORIZATION.
Signatures: DO NOT SIGN UNLESS YOU HAVE READ AND UNDERSTAND ALL TERMS AND CONDITIONS OF THIS DOCUMENT
