Chimney Sweep Application

Section A: Applicant Information

Company Name:

DBA:

Owner's Name:

Physical Address:

Physical City:

Physical State:

Physical Zip:

Mailing address same as physical address?

Yes

Mailing Address:

Mailing City:

Mailing State:

Mailing Zip:

Telephone Number:

Fax Number:

Cell Number:

Email:

Website:

How did you hear about us?

If other

Are You a Member of the National Chimney Sweep Guild (NCSG)?

Yes

Member ID#:

Are You a Member of any other associations?

Yes

If yes, please list:

Does the applicant have a policy with Veracity currently?

Yes

Total Years in Trade:

Date Business Started:

Section B: Prior/Current Insurance Information

Current Insurance Company:

Expiration Date:

Liability Premium:

Deductible Requested $:

Proposed Effective Date:

Have You Ever had Similar Insurance Cancelled or Non-renewed?:

Yes

If yes, please explain:

Section C: Insurance Limits (General Liability)

Do You Require Limits Higher than $1,000,000 Per Occurrence / $2,000,000 Aggregate?:

Yes

Are You Interested in Soot/Creosote Coverage?:

Yes

What Limit Would You Like Quoted?

Section D: Underwriting Information

Owner(s) Information

Number of Employees (Excluding Owner)

Full-time:

Part-time:

Number of Certifications (Both Owner and Employees)

CSIA Certified

CDET Certified

NFI Certified

Estimated Payroll for the next 12 Months (Excluding Owner)

Office/Clerical

In Field

Breakdown Type of Work Done by Percentage:

Chimney Sweeping & Service (liners, dampers, etc.) %

Inspection Only Jobs (no sweeping, etc.) %

Stove/Barbeques/Fireplace Inserts %

Masonry %

Carpentry %

Roof Repair %

Spas/Hot Tubs %

HVAC Work %

Other %

Explain other

Estimated GROSS RECEIPTS for the next 12 Months $

% Service & Installation

% Product Sales

Breakdown of Product Sales by Product Type:

Chimney Products (caps, dampers, liners, etc.) %

Stove Manufacturing %

Accessories %

Spa/Pool %

Stoves, Grills, Fireplace Inserts %

Plumbing Supplies %

Breakdown of Work Done by Percentage

Commercial %

New Custom Residential %

New Multi-Family Residential %

New Tract Residential %

Existing Multi-Family Residential %

Existing Single Family Residential %

Maximum number of units in multi-family buildings where work is done:

Does work on New Residential Construction Include Subdivisions greater than 20 Homes?

Yes

Is New Residential Construction Performed in any of the Following States: AZ, CA, CO, GA, NM, NV, OR, WA

Yes

Any LPG Work?

Yes

If yes, what percentage

Any Natural Gas Work?

Yes

If yes, what percentage

Do you have any Safety Training or Programs in Place?

Yes

If yes, please explain:

Do you work in any other State?

Yes

Which States?

Section E: Subcontracted Work

Annual cost of Subcontractors $

What work are the subcontractors hired to do?

Are certificates of insurance obtained prior to subcontractors starting work?

Yes

Are you named as an additional insured on the subcontractors policy?

Yes

Do subcontractors carry Workers Compensation?

Yes

Do you use a Sub-Contractors Agreement?

Yes

If yes, please attach a copy

I understand that I am required to obtain a certificate of insurance from each and every subcontractor, naming me as an additional insured, with liability limits equal or greater than my policy.

Section F: Retail Operations

Do you have a Retail Operation?

Yes

What is the Square Footage of Retail Space

What is the Square Footage of Warehouse Space

Are Customers Allowed in Warehouse Space?

Yes

If yes, please describe under what circumstances

Do you Maintain your Parking lot/entry way/walkway?

Yes

If yes, please describe

Do you have Security Cameras inplace?

Yes

Do you Operate any type of fire on Premise for Demonstration Purposes, or other reasons?

Yes

If yes, please describe

Section G: Property Insurance

Do you need commercial property coverage?

Yes

Building coverage limit:

Business personal property limit:

Street address:

City:

State:

Zip:

Is this your home/residence

Yes

Facility Type:

Rented

Leases

Owned

Total area in Sq. Ft. you Occupy

Property Deductible Requested

$500

$1,000

Construction Type:

Frame

Brick

Metal

Are you within 10 miles of a Coast:

Yes

Year built

What year were the following updated/replaced:

Plumbing

Heating

Wiring

Roof

Distance From Fire Hydrant

Distance From Fire Station

Alarm:

Burglar

Fire

Both

Alarm type:

Local Gong

Central Station

Fire Protection:

Sprinkler System

Fire Alarm

Section H: Residential/Commercial Operations

Do you maintain client sign off for:

Inspections

Work Completed

Other

If other, please explain:

Maximum height in stories worked?

Do you use scaffolding or cranes?

Yes

Do you perform any blasting, demolition, or welding?

Yes

Do you comply with NFPA 211 or NFI Guidelines when local codes do not supersede?

Yes

Are you familiar with, and do you adhere to all local laws and regulations relative to you business?

Yes

Have you ever been cited for non-compliance of any statutory regulations?

Yes

If yes, please explain in detail:

Do you retain a copy of all documentation, photos, videos, and email?

Yes

If yes, for how long?

What is your normal procedure when a client's furniture or carpet has been coiled or damaged?

What methods do you use to limit access to work areas around and under ladders as well as around any lifts or vacuum trucks to prevent injury or access to the public or client?

Do you use a commercial grade vacuum for removal of debris and/or dust control when sweeping?

Yes

Do you install stainless steel liners for fireplaces or other appliances?

Yes

Do you install ceramic tile liners?

Yes

Do you install cast in place liners?

Yes

Do you perform a level 2 inspection prior to installation?

Yes

What percent of your gross sales derive from liner installations?

List the training and/or certifications that would qualify you to install liners:

Do you inspect, clean or repair free-standing wood or gas stoves?

Yes

What is the percentage of your total business with this type of service performed?

What is the percentage of gas stoves?

What is the percentage of wood stoves?

Section I: Claims History for the Last 5 Years

Are you, any person, or organization proposed in this insurance aware of any incident, circumstance, situation, condition, occurrence, or event which may result in a claim?

Yes

Describe all claims (regardless of fault) that have occurred in the last 5 years. If none, state None:

Please attach a copy of Loss History from current/prior insurance carriers

I hereby certify that the above claim information is true to the best of my knowledge:

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects that person to criminal and civil penalties (In Oregon, the aforementioned actions may constitute a fraudulent insurance act which may be a crime and may subject the person to penalties). (In New York, the civil penalty is not to exceed five thousand dollars ($5,000) and the stated value of the claim for each such violation). (Not applicable in AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN, NM, OK, PR, RI, TN, VA, VT, WA and WV).

Applicable in AL, AR, AZ, DC, LA, MD, NM, RI and WV: Any person who knowingly (or willfully in MD) presents a false or fraudulent claim for payment of a loss or benefit or who knowingly (or willfully in MD) presents false information in an application for insurance is guilty of a crime and may be subject to fines or confinement in prison.

Applicable in Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the department of regulatory agencies.

Applicable in Florida and Oklahoma: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony (In FL, a person is guilty of a felony of the third degree).

Applicable in Kansas: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act.

Applicable in Maine, Tennessee, Virginia and Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.

Applicable in Puerto Rico: Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation by a fine of not less than five thousand dollars ($5,000) and not more than ten thousand dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances be present, the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2) years.

THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE INQUIRY HAS BEEN MADE TO OBTAIN THE ANSWERS TO QUESTIONS ON THIS APPLICATION. HE/SHE REPRESENTS THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HER KNOWLEDGE.

Applicants Name:

(Application must be signed by Insured)

Date:

Applicants Signature:

If you are currently working with a Veracity Broker please enter their name:

Broker Name