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IDAL Insurance Program
Application
Download Printable Application
IDAL Insurance Application
For questions regarding this, call 866-916-9420.
"
*
" indicates required fields
Applicant Information
Category
*
Renewal
New Application
Are you a current member of IDAL?
*
Yes
No
Applicant Name
*
Legal Business Name
*
Address
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone Number
*
Email Address
*
Insurance Information
Policy Effective Date
MM slash DD slash YYYY
Do you perform any work other than what is necessary and Incidental to Decorative Painting, Decorative Plastering, and Wall Stenciling?
*
Yes
No
Provide a description of all operations
Total Gross Sales (Revenue) projected for the next 12 months. Enter only one amount, not a range. (Example: $40,000)
*
Do you require proof of insurance for all subcontracted employees you hire? (1099 employees)
*
Yes
No
N/A (Don't Hire Subcontractors)
What percentage of your business is subcontracted out?
*
Please enter a number from
0
to
100
.
During the Past three years has any company ever cancelled, declined, or refused to renew similar coverage?
*
Yes
No
Any Claims in the last 3 Years?
*
Yes
No
Claim Date
MM slash DD slash YYYY
Claim Amount
Description of Claim
Do you perform regular/straight painting (painting that is not considered decorative nor base coats to decorative finishes)?
Yes
No
What percentage of your work is straight painting?
*
Please enter a number from
0
to
100
.
Do you perform any exterior painting?
Yes
No
What percentage of your work is exterior painting?
*
Please enter a number from
0
to
100
.
Disclaimer: the insurance policy excludes any work performed over 6 stories or 72 feet above ground level.
E-Signature
Consent
*
I agree that the following is true
*
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.
Applicants Signature
*
Applicant's Printed Name
*
Date
*
MM slash DD slash YYYY
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