Scottsdale Insurance Company Adm. Office: Home Office: One Nationwide Plaza Adm. Office: Scottsdale Surplus Lines Insurance Adm. Office: Scottsdale Indemnity Company Scottsdale, Home Office: One Nationwide Plaza SWIMMING POOL MAINTENANCE AND MANAGEMENT SUPPLEMENTAL APPLICATION (Complete in addition to the ACORD General Liability Application) Agency Name: Applicant’s Name: Agent No.: Location Address: Phone No.: E-mail: From: To: PROPOSED EFFECTIVE DATE: 12:01 A.M., Standard Time at the address of the Applicant ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE” (N/A) A. GENERAL INFORMATION: 1. Does risk engage in the generation of power, other than emergency back-up power, for their own use or sale to power companies? Yes No If yes, describe: 2. Does applicant have any other business ventures for which coverage is not requested? Yes No If yes, explain and advise where insured: B. POOL MAINTENANCE OPERATIONS: Employee Data Number Annual Payroll Owner(s) only $ Maintenance: Full-time $ Part-time $ Leased or Subcontracted Number Annual Cost Leased employees—maintenance: Full-time $ Part-time $ Independent contractors—maintenance: Full-time $ Part-time $ 1. Limited Coverage For Property Damage From Swimming Pool Pop Up limits: $50,000 each occurrence/$100,000 aggregate (included) Other Limits: Exclude Yes No 2. Does applicant rent portable spas? 3. Does applicant manufacture or sell any products under their own label? Yes No If yes, complete and submit the Products Liability Application.
Scottsdale Insurance Company Home Office: One Nationwide Plaza Adm. Office: Scottsdale Indemnity Company Home Office: One Nationwide Plaza Adm. Office: Scottsdale Surplus Lines Insurance Adm. Office: Scottsdale, SWIMMING POOL MAINTENANCE AND MANAGEMENT SUPPLEMENTAL APPLICATION (Complete in addition to the ACORD General Liability Application) Applicant’s Name: Location Address: Agency Name: Agent No.: Phone No.: E-mail: PROPOSED EFFECTIVE DATE: From: To: 12:01 A.M., Standard Time at the address of the Applicant ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE” (N/A) A. GENERAL INFORMATION: 1. Does risk engage in the generation of power, other than emergency back-up power, for their own use or sale to power companies? Yes No If yes, describe: 2. Does applicant have any other business ventures for which coverage is not requested? Yes No If yes, explain and advise where insured: B. POOL MAINTENANCE OPERATIONS: Employee Data Number Annual Payroll Owner(s) only $ Maintenance: Full-time $ Part-time $ Leased or Subcontracted Number Annual Cost Leased employees—maintenance: Full-time $ Part-time $ Independent contractors—maintenance: Full-time $ Part-time $ 1. Limited Coverage For Property Damage From Swimming Pool Pop Up limits: $50,000 each occurrence/$100,000 aggregate (included) Other Limits: Exclude 2. Does applicant rent portable spas? Yes No 3. Does applicant manufacture or sell any products under their own label? Yes No If yes, complete and submit the Products Liability Application.