Crane And Rigging Supplemental Application
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- Darcy Mitchell Eaton
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1 <<<Enter your header info here>>> << Click mouse in fill in field below to continue>> Crane And Rigging Supplemental Application TO BE USED WITH COMMERCIAL GENERAL LIABILITY APPLICATION (ACORD 125) All questions must be answered in full. Application must be signed and dated by the applicant. Applicant s Name Agent Applicant Mailing Address Applicant s Phone Number Web Address Inspection Contact Proposed Policy Period to Phone Number for Inspection Contact Applicant is Individual Partnership Corporation Joint Venture Other Location #1 Location #2 Location #3 UNDERWRITING INFORMATION 1. Years in Business 2. Provide geographic area of operation 3. Estimated breakdown of total gross sales and payroll for the following categories CATEGORY PAYROLL GROSS SALES Crane rental with operator $ $ Bare crane rental (Attach rental agreement) $ $ Heavy Hauling or machinery moving $ $ Millwright work including machinery $ $ Installation service and repair $ $ Rigging (if done as a separate operation to above) $ $ Miscellaneous (describe below) $ $ 4. Do you specialize in any particular field of operation or for any one specific industry? Yes No If yes, provide complete details below. S362s (04/09) Page 1 of 5
2 UNDERWRITING INFORMATION (Continued) 5. Provide detailed description of all equipment used in operations (e.g. forklift, crane, etc.). 6. Provide detailed description including cost of last 5 jobs. (Attach separate sheet, if needed) 7. Is welding or electrical hook up involved with the operations?... Yes No 8. Do you rent any equipment to others?... Yes No If yes, provide description of equipment including gross sales 9. Number of employees by category UNION NON-UNION Equipment operators Technicians or maintenance personnel Leased workers LOSS CONTROL & MAINTENANCE 1. Is there a formal written loss control or safety program?... Yes No 2. Is one employee responsible for your safety program?... Yes No Provide Name of individual. Do you hold regular safety meetings with all employees on a regular basis?... Yes No 3. Do you have screening and/or reference procedures for all new operators?... Yes No 4. Are random drug or alcohol testing procedures outlined in a written manual provided to all employees?... Yes No 5. What is the age requirement for operators? Minimum Maximum 6. Do you keep a written scheduled maintenance program of all equipment?... Yes No 7. Do you have a formal report to be filed on all accidents or injuries? (Attach copy)... Yes No 8. Do you obtain certificates of insurance on all crane rentals?... Yes No 9. Do you obtain MVR s on all drivers?... Yes No 10. Are all cranes inspected or certified?... Yes No If no, provide detailed information. 11. Do you maintain Commercial Automobile Liability coverage on all units driven over the road?... Yes No If no, provide details. If yes, provide carrier, limits, and policy term. S362s (04/09) Page 2 of 5
3 LOSS CONTROL & MAINTENANCE (Continued) 12. Do you perform any of the following services?... Yes No If yes, provide details. (a) Dual Lifts?... Yes No (b) Personnel lift, or placement?... Yes No (c) Work in excess of three stories?... Yes No (d) What is the maximum height of work performed? Provide the following information for RIGGING performed for others: (a) Estimated number of jobs performed annually. (b) Estimated duration of each job. (c) Number of jobs in progress at any one time. Maximum Minimum Average (d) Cost or Value of each on hook installation. Maximum Minimum Average 14. Attach each item to this application. List Equipment including Manufacturer, Values, Serial Number, Tonnage, Boom length and Jib length. Financial Statement. Copy of Rental Agreement for equipment leased to others. Copy of Accident or Incident report. Copy of daily inspection log. Copy of loss control or safety plan. This application shall not be binding unless and until confirmation by the Company or its duly appointed representatives has been given, and that a policy shall be issued and a payment shall be made, and then only as of the commencement date of said policy and in accordance with all terms thereof. The said applicant hereby covenants and agrees that the foregoing statements and answers are a full and true statement of all the facts and circumstances with regard to the risk to be insured, and the same are hereby made the basis and conditions of the insurance and a warranty on the part of the Insured. IMPORTANT NOTICE As part of our underwriting procedure, a routine inquiry may be made to obtain applicable information concerning character, general reputation, personal characteristics, and mode of living. Upon written request, additional information as to the nature and scope of the report, if one is made, will be provided. To Insureds in the States of: FRAUD STATEMENT Alabama, Alaska, Arizona, California, Connecticut, Delaware, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Maine, Massachusetts, Maryland, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, New Hampshire, Nevada, North Carolina, North Dakota, Oregon, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, West Virginia, Wisconsin, Wyoming: NOTICE: In some states, any person who knowingly, and with the intent to defraud any insurance company or other person, files an application for insurance or statement of claim containing any materially false information, or, for the purpose of misleading, conceals information concerning any fact material thereto, may commit a fraudulent insurance act which is a crime in many states. Penalties may include imprisonment, fines, or a denial of insurance benefits. Arkansas presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. S362s (04/09) Page 3 of 5
4 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 claiming with regard to a settlement or award payable for insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. District of Columbia WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. Florida Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of claim containing any false, incomplete, or misleading information is guilty of a felony of the third degree. Kentucky 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. Louisiana presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. New Jersey Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties New Mexico presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties. New York Any person who knowingly and with intent to defraud any insurance company or other person files an application for commercial insurance or a statement of claim for any commercial or personal insurance benefits containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, and any person who, in connection with such application or claim, knowingly makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, damage or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or an insurance company commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the value of the subject motor vehicle or stated claim for each violation. Ohio Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. Oklahoma WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. Pennsylvania Any person who knowingly and with intent to defraud any insurance company, or other person, files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent act, which is a crime, and subjects such person to criminal and civil penalties. S362s (04/09) Page 4 of 5
5 Rhode Island NOTICE: Under Rhode Island law, there is a criminal penalty for failure to disclose a conviction of arson. In some states, any person who knowingly, and with intent to defraud any insurance company or other person, files an application for insurance or statement of claim containing any materially false information, or, for the purpose of misleading, conceals information concerning any fact material thereto, may commit a fraudulent insurance act, which is a crime in many states. Virginia It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. Washington It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purposes of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits. Producer s Signature Date Applicant's Signature Date S362s (04/09) Page 5 of 5
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TELECOMMUNICATION TOWERS SUPPLEMENTAL APPLICATION (Complete in addition to the ACORD General Liability Application)
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Present Crime Insurance Program: (Include primary AND excess, if applicable) If not applicable, please check here:
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PRIVATE COMPANY THIRD PARTY ADMINISTRATOR QUESTIONNAIRE
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Checkpoint Payroll Sources All Payroll Sources
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WATER SUPPLY COMPANIES AND IRRIGATION SYSTEMS SUPPLEMENTAL APPLICATION (Complete in addition to ACORD General Liability Application)
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CONSULTANT LIABILITY APPLICATION
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APPLICATION FOR FIDUCIARY LIABILITY COVERAGE PART
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Accidental Death Claim Instructions
Phone : 1-877-722-1959 Fax: 443-279-2901 Accidental Death Claim Instructions The Claimant/ Insured should complete and sign the Accidental Death Insurance claim form in full and return it with the documentation