POWER GENERATION APPLICATION SUPPLEMENT

Transcription

1 Chubb Group of Insurance Companies 15 Mountain View Road, Warren, New Jersey POWER GENERATION APPLICATION SUPPLEMENT APPLICANT INFORMATION 1. Insured Name: 2. Insured Address: 3. Insured Contact: Phone: 4. Operations: A B C D Location: MW Capacity: Fuel: Technology Used: Base Load: Peaking: Dispatch: Merchant: Operator: COVERAGES Please check coverages and limits desired COVERAGE LIMITS OF INSURANCE Property General Liability Auto* Workers Compensation* Pollution Umbrella* Other *Complete ACCORD application or equivalent Form (Ed ) Page 1 of 5

2 LOSS HISTORY - List paid and pending losses over last 5 years for submitted coverages DESCRIPTION DATE OF LOSS LOSS AMOUNT PROPERTY 1. Values: A B C D Building: Turbine/Generator: Boiler: Transformer: Balance of Plant: Spares: Total Property (1): Business Income (2): Total: 1. Attach a major equipment listing including Make, Model and Capacity for each location and 2. Attach a completed Business Income worksheet for each location. 2. Coverage Extensions: Type Sublimit Type Sublimit Earthquake $ Debris Removal $ Flood $ Pollution Cleanup $ Windstorm $ Building Ordinance $ Transit $ Valuable Papers $ Extra Expense $ Service Interruption $ Contingent BI* $ Other $ * Include a list of contributing and recipient Contingent Business Income locations with income attributed to each location Deductible: Real & Personal $ B.I. $ Windstorm $ Transit $ Contingent BI* $ Earthquake $ Flood $ 4. Is business interruption coverage desired? Yes No If yes, describe contingency plan (for critical component failure, fire, etc.): Form (Ed ) Page 2 of 5

3 5. Preventative maintenance per mfg. recommendations? Yes No Does it account for operational/cycle changes? Yes No 6. Predictive maintenance employed at each location? Yes No If yes, please answer the following. A. Is there an established vibration monitoring program in place? Yes No If yes, is it done in house or by an outside firm? How often are vibration studies completed on rotating machinery? B. Is there a formal lube oil analysis program in place? Yes No If yes, how often? C. Do you have a formal transformer oil analysis program in place? Yes No If yes, how often are the main step-up and service station transformers tested? GENERAL LIABILITY 1. If any work is subcontracted, please describe subcontractor controls Subcontractor coverage required: General Liability Yes No Limit Required: Automobile Yes No Limit Required: Workers Compensation Yes No Limit Required: Umbrella/Excess Liability Yes No Limit Required: Are you named as an additional insured? Yes No Do you waive your rights of subrogation? Yes No Is contractual indemnification? Mutual To You To Subcontractor Are certificates of insurance required for all subcontractors? Yes No 2. Please detail annual energy generation by location: A B C D Annual KWH: Sold to: Utility: Host Facility: Other: Annual # Steam: Sold to: Utility: Host Facility: Other: 3. Do you own maintain any electric or steam transmission distribution lines? Yes No If yes, describe capacity, type and length (miles): Form (Ed ) Page 3 of 5

4 UMBRELLA 1. Additional underlying insurance information Auto W.C. Other Limits Carrier Premium 2. Auto A. Number of Vehicles PP Light Med. Heavy Radius of Operations Less than 50 miles miles Greater than Other B. Driver Selection/Training Criteria Is a formal driver safety training program utilized for all drivers? Yes No Do all drivers maintain valid licenses for the class of vehicle operated? Yes No Are motor vehicle operating records reviewed for all drivers? Yes No (If no, attach a lit of drivers including date of birth, license number and state) 3. International exposures Describe operations and location 4. Watercraft of aircraft exposure? Yes No If yes, describe: POLLUTION 1. Continuous air emissions monitoring? Yes No 2. List regulated and/or hazardous by products from operations and how they are disposed A B C D Ash: Disposal: Lubricating Oil: Disposal: Other: Disposal: Is appropriate documentation maintained for all regulated material disposal? Yes No 3. Site assessment performed at all locations within last 5 years? Yes No If yes, did it verify that location was a clean site? Yes No If no, describe existing contamination: Page 4 of 5 Page 4 of 5

5 PRODUCER INFORMATION Producer/Agency: Mailing Address: Phone Number: Fax Number: DECLARATION AND SIGNATURE I have read the above Application. I declare that to the best of my knowledge and belief the statements and information in this Application and any attachments thereto are true, accurate and complete. This information is given to the insurer for the specific purpose of obtaining insurance coverage. It is agreed that if any information given in this Application or in any attachments thereto is materially false, inaccurate or incomplete, the insurer may deny coverage or cancel the policy. Signature for First Named Insured Title Date (May not be signed by Producer) Submitted by: Producer FOR NEW YORK AND OHIO APPLICANTS: 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. Form (Ed ) Page 5 of 5

6 The undersigned persons declare that to the best of their knowledge the statements set forth above and in any attachments to this APPLICATION are true and correct, and that every reasonable effort has been made to obtain sufficient information to facilitate the proper and accurate completion of this APPLICATION. The undersigned agree that if any significant change in the condition of the Applicant is discovered between the date of this APPLICATION and the effective date of the policy which would render this APPLICATION inaccurate or incomplete, notice of such change will be reported in writing to the COMPANY immediately and, if necessary, any outstanding quotation may be modified or withdrawn. The undersigned persons understand and further agree that the completion and signing of this APPLICATION neither binds the COMPANY to sell nor the Applicant to purchase the insurance. PLEASE NOTE: ONLY DULY APPOINTED AGENTS OF THE COMPANY AND LICENSED BROKERS ARE AUTHORIZED TO SOLICIT APPLICATIONS FOR COVERAGE. AGENTS AND BROKERS ARE NOT AUTHORIZED TO BIND COVERAGE. NO COVERAGE SHALL BE PROVIDED UNLESS THE COMPANY ACCEPTS THE APPLICATION AND BINDS THE COVERAGE. False Information: Any person who, knowingly and with intent to defraud an insurance company or other person, files an Application or insurance containing any false information, or conceals for the purpose of misleading, information concerning any material fact thereto, commits a fraudulent insurance act, which is a crime. False Information (California Only): For your protection, California law requires the following to appear on this form: Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. False Information (Colorado Only): 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 claimant with regard to a settlement or award payable from insurance proceeds, shall be reported to the Colorado division of insurance within the department of regulatory agencies. False Information (Florida Only): Any person who, knowingly and with intent to injure, defraud, or deceive any insurer, files a statement of claim or an Application containing any false, incomplete, or misleading information, is guilty of a felony of the third degree. 1

7 False Information (Louisiana Only): Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. False Information (Maine Only): It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. False Information (Nebraska Only): files an Application for insurance containing any false information, or conceals for the purpose of misleading, information concerning any material fact thereto, commits a fraudulent insurance act, which is a crime, where such person subsequently submits a claim. False Information (New Mexico Only): Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties. False Information (New York Only): files an Application for insurance containing any materially false information, or conceals information concerning any material fact thereto, for the purpose of misleading, 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 stated value of the claim for each such violation. False Information (Ohio Only): Any person who, with the intent to defraud or knowing that he 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. False Information (Oklahoma Only): 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. 2

8 False Information (Oregon Only): files an Application for insurance containing any false information, or conceals for the purpose of misleading information containing any material fact thereto, may be guilty of a insurance fraud. False Information (Pennsylvania Only): files an Application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any material fact thereto, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. False Information (Vermont Only): files an Application for insurance containing any false information, or conceals for the purpose of misleading, information concerning any material fact thereto, commits a fraudulent insurance act, and the policy may be voided. False Information (Virginia Only): It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the insurance company. Penalties include imprisonment, fines, and denial of insurance benefits. 3