CONTRACTORS EQUIPMENT APPLICATION

Transcription

1 CONTRACTORS EQUIPMENT APPLICATION Name of Insured Mailing Address City State Zip Phone #: Eff Date Exp Date Insured Contact Name: LOSS HISTORY Expiring Term Prior Year Prior Year Prior Year Prior Year Carrier Premium # of Losses Total Incurred Deductible Loss Control Employed Please provide a description of each loss LIMITS: $ Total of Scheduled Equipment $ Any one tool yours Total of Your Tools $ $ Any one tool Employee Total Employee Tools $ $ Any one leased/rented Eq. Total leased/rented Eq, $ $ Any one borrowed item Total borrowed item $ $ Equipment Rental Reimbursement Spare Parts/Fuel $ $ Any one Construction Trailer Total Construction Trailers$ BACKGROUND Type of work performed Radius Number of years in business (provide description of past experience if under 5 years) Any policy or coverage declined, cancelled or non renewed during the past 3 years? Y / N Any bankruptcies, tax or credit liens, in the last 5 years? Y / N EQUIPMENT STORAGE AND SECURITY: When not in use, at what address is equipment stored? If stored indoors: Construction of the building If stored outdoors: Is the lot fenced and lighted: Y / N Central Station Alarm? Y / N Cameras & recording: Y / N What is the operation inside? Watchservice Y / N Sprinklered? Y / N # of Fire Extinguishers Regular police patrols? Y / N Maximum value at storage site $ Maximum values at a job site $ When stored on site overnight:

2 Is equipment disabled by removing an essential part (i.e. spark plug, wire, distributor cap) Y / N Are there regular police patrols? Y / N Are any of the following used? Kill Switches? LoJack/GPS? Fire Extinguishers? Immobilized Office Trailers? Steering Wheel Locks? Tire/Wheel Axel Locks? Locked Hood Side Plates? Locked Gang Boxes? Locked Fuel Caps? Alarmed Tool Trailers? Chains & Locks? Alarmed Office Trailers? Is equipment registered on the National Equipment Register? Y / N MAINTENANCE Is a written maintenance program in place? Y / N (please provide) Do employees physically inspect equipment before use each day? Y / N Does the check involve completing a checklist? Y / N Are the checklists stored? Y / N Are hydraulic hoses included in the check? Y / N LEASED / RENTED / BORROWED EQUIPMENT Estimated expenditures for the year: Actual Expenditures last year: Types of equipment leased/rented: Average # of days rented Maximum # of days rented Estimated # of times equipment is borrowed: Actual # of times equipment is borrowed: Average # of days borrowed Maximum # of days borrowed Is there a contract between the parties when borrowing equipment? Y / N Is there some sort of documentation to record the condition of equipment when received? Y / N EQUIPMENT HAULING 2 P age

3 $ Any one vehicle Hauling equipment of others for a fee $ Any one occurrence $ Estimated annual receipts Drivers are employed: % FT PT Are drivers bonded? Y N Annual Turnover How often are they reviewed? Are MVR s checked annually? Y / N At what point is corrective action taken? Are physicals performed annually? Y / N Are employees randomly checked for drugs/alcohol? Y / N At hiring, which of the following is/are done? Physicals Drug/Alcohol Check Background Check Minimum Amt of Exp? MVRs? Road Test Minimum Age Driver Mgmt System Check? Are vehicles left loaded and unattended at any point? Y N In Transit: How many drivers per truck? GPS/ LoJack Trailer Alarm Person in vehicle Locked Trailer Alarmed Cab Are a driver s credentials and instructions checked before releasing a load? Y / N Are routes planned in advance? Y / N Are horizontal and vertical clearances checked? Y / N Are loads secured ANYTIME the trailer is in motion? Y / N Will lead/pace cars be employed? Y / N CRANES Do any of the crane operators have less than 5 years experience? Y / N a. Are they licensed? Y / N b. Unionized? Y / N How often is operator training refreshed? Y / N Are all cranes equipped with proximity warning devices that emit sirens, flash warning lights, and/or shut down the vehicle when the boom gets too close to high voltage power lines? Y / N Are all cranes equipped with load monitoring devices that force the crane to automatically shut down if a load is deemed to be "unsafe" (e.g., unbalanced, exceeds the crane's maximum lifting capacity)? Y / N Are outriggers consistently used to help cranes maintain balance and stability? Y / N If yes, Is the ground checked for sufficient support prior to deployment? Y / N Are tandem lifts performed? Y / N Are load capacities checked before lifting? Y / N Does the insured use ground spotters with tag lines and an experienced signal person when performing its crane operations? Y / N CONTINUING LEASE OR RENTAL PAYMENTS 3 P age

4 $ Any one item $ Avg monthly lease payments $ Annual Aggregate $ Avg monthly rental payments List of scheduled item # s leased: ADDITIONAL COVERAGES $ Fraud & Deceit $ Recharge of Fire Extinguishing Equipment $ Reward for Recovery of Stolen Equipment Are employees trained to check credential before turning over equipment? Y / N WATERBORNE $ Waterborne Limit Describe waterborne work Is equipment driven on to barges Y / N How is ballast handled? How far off shore does the insured work? On average Maximum EQUIPMENT RENTED TO OTHERS $ Any one Occurrence $ Estimated annual receipts earned Is a contract between the parties used? Y / N Please provide a copy Are certificates of insurance for property damage retained? Y / N Are limits reviewed for adequacy? Y / N Is a security deposit kept? Y / N Is a background and credit check performed Y / N Are condition reports done prior the item s departure? Y / N Immediately upon return? Y / N Who is responsible for pick up and delivery? PROPERTY LOANED TO OTHERS $ Any one Occurrence Estimated annual number of times loaned Is a contract between the parties used? Y / N Please provide a copy Are certificates of insurance for property damage retained? Y / N Are limits reviewed for adequacy? Y / N Is a security deposit kept? Y / N Is a background and credit check performed Y / N Are condition reports done prior the item s departure? Y / N Immediately upon return? Y / N Who is responsible for pick up and delivery? Parties to whom equipment is loaned (add additional sheet if necessary): Name of party Street Address City, State & Zip SCHEDULE OF EQUIPMENT: Complete the following chart for each piece or attach a spreadsheet or list that contains the same information. 4 Page

5 # Year Manufacturer Type Model Serial # (last 6) Limit LOSS PAYEES Item # Loss Payee Mailing Address 5 P age