IDAL Insurance Application

Applicant Information

Category:*	Renewal    New
Are you a current member of IDAL:*	Yes No
Applicant Name:*
Legal Business Name:*
Address:*
City:*
State:*
Zip:*
Phone Number: (xxx) xxx-xxxx*
Email Address:*

Insurance Information

1. Policy effective date:
2. Do you perform any work other than what is necessary and Incidental to Decorative Painting, Decorative Plastering, and Wall Stenciling?	Yes No
a. Provide a description of all operations:
3: Total Gross Sales (Revenue) projected for the next 12 months:
4. Do you require proof of insurance for all subcontracted employees? (1099 employees)	Yes No N/A (Don't Hire Subcontractors)
a. What percentage of your business is subcontracted out?
5: During the Past three years has any company ever cancelled, declined, or refused to renew similar coverage?	Yes No
6. Any Claims in the last 3 Years?	Yes No
a. Claim Date:
b. Claim Amount:
c. Description of Claim:
7. Do you perform regular/straight painting (painting that is not considered decorative nor base coats to decorative finishes)?	Yes No
a. What percentage of your work is straight painting?
8. Do you perform any exterior painting?	Yes No
a. What percentage of your work is exterior painting?
Disclaimer: the insurance policy excludes any work performed over 6 stories or 72 feet above ground level.

E-Signature

The applicant represents that the above statements and facts are true and that no material facts have been suppressed or misstated and further acknowledges that the answers provided herein are based on reasonable inquiry and/or investigation.

Completion of this form does not bind coverage. Applicant’s acceptance of the company’s quotation is required prior to binding coverage and policy issuance.

All written statements and materials furnished to the company in conjunction with this application are hereby incorporated by reference into this application and made a part hereof.

Applicant's Signature (type full name):*
Date:*

I Agree