roofers supp sic rou074 201104
8417 Patterson Avenue Richmond, Virginia 23229 Telephone: (804) 741-7999 WATTS: (800) 628-2967 Fax: (804) 741-9401 www.royaloakunderwriters.com
ROYAL OAK UNDERWRITERS, INC. Excess and Surplus Lines Insurance Wholesalers
ROOFERS PROGRAM APPLICATION General Liability APPLICANT INFORMATION Name Address City, State, Zip Telephone
Contractor License Number (if required)
Policy Term: Business Description:
Individual Partnership Corporation Other
Limits Requested: Occurrence
Personal Injury/Advertising
General Aggregate
Medical Payments
Products/Comp Ops Aggregate
Fire Legal
Estimated annual payroll $
Estimated annual receipts $
Years in business
Average number of employees
Years experience in roofing
Percentage use of part-time employees
%
Percentage use of subcontractors
%
Percentage use of hot tar
%
Percentage use of torchdown work
%
Percentage of commercial jobs to total
%
(Note: Subcontractors must provide certificates of general liability and workers' compensation insurance)
Maximum height of buildings worked on
Describe largest typical job contracted on Describe any use of cranes or heavy equipment Workers' Compensation insurer and policy number
THREE YEAR LOSS EXPERIENCE Date
Losses (description and amounts paid and incurred)
SAVE rou074-201104
Page 1 of 2
Royal Oak Underwriters, Inc.
ROYAL OAK UNDERWRITERS, INC. Excess and Surplus Lines Insurance Wholesalers
8417 Patterson Avenue Richmond, Virginia 23229 Telephone: (804) 741-7999 WATTS: (800) 628-2967 Fax: (804) 741-9401 www.royaloakunderwriters.com
Comments _________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ ____________________________________________ ____________________________________________ ______________________________________ Applicant Signature
____________________________________________ Producer Name & Address
______________________________________ Date
Reset Form rou074-201104
Submit by E-mail Page 2 of 2
Print Form
SAVE
Royal Oak Underwriters, Inc.
ROYAL OAK UNDERWRITERS, INC. Excess and Surplus Lines Insurance Wholesalers
ROOFERS PROGRAM APPLICATION General Liability APPLICANT INFORMATION Name Address City, State, Zip Telephone
Contractor License Number (if required)
Policy Term: Business Description:
Individual Partnership Corporation Other
Limits Requested: Occurrence
Personal Injury/Advertising
General Aggregate
Medical Payments
Products/Comp Ops Aggregate
Fire Legal
Estimated annual payroll $
Estimated annual receipts $
Years in business
Average number of employees
Years experience in roofing
Percentage use of part-time employees
%
Percentage use of subcontractors
%
Percentage use of hot tar
%
Percentage use of torchdown work
%
Percentage of commercial jobs to total
%
(Note: Subcontractors must provide certificates of general liability and workers' compensation insurance)
Maximum height of buildings worked on
Describe largest typical job contracted on Describe any use of cranes or heavy equipment Workers' Compensation insurer and policy number
THREE YEAR LOSS EXPERIENCE Date
Losses (description and amounts paid and incurred)
SAVE rou074-201104
Page 1 of 2
Royal Oak Underwriters, Inc.
ROYAL OAK UNDERWRITERS, INC. Excess and Surplus Lines Insurance Wholesalers
8417 Patterson Avenue Richmond, Virginia 23229 Telephone: (804) 741-7999 WATTS: (800) 628-2967 Fax: (804) 741-9401 www.royaloakunderwriters.com
Comments _________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ ____________________________________________ ____________________________________________ ______________________________________ Applicant Signature
____________________________________________ Producer Name & Address
______________________________________ Date
Reset Form rou074-201104
Submit by E-mail Page 2 of 2
Print Form
SAVE
Royal Oak Underwriters, Inc.
