Emery & Karrigan. Crane & Rigging Application. 1. Full Name of Insured including all owned or controlled subsidiaries

Transcription

1 Emery & Karrigan Crane & Rigging Application 1. Full Name of Insured including all owned or controlled subsidiaries 2. Current Mailing Address: Location Address: Federal ID Number: Address: Website Address: 3. Individual Co-Partnership Corporation Other 4. (a) How many years have you been in business under the present name? (b) If less than 3 years, please provide full resume of principals experience or previous name(s) of company (c) Name of person to be contacted in your organization for purpose of inspection Name: Phone Number: 5. What is your full geographic area of operation, broken down per State: 6. Effective Date 7. Description of all Operations

2 8. Please provide estimated breakdown of annual gross receipts and payroll for the following categories Payroll Receipts Crane Rental with Operator Bare Crane Rental Millwright work Steel Erection Rigging (if done separately) Heavy Hauling Sales of Equipment Scaffolding Miscellaneous (describe) Please describe any installation and repair or removal work for any of the above classes: 9. What kind of goods/equipment are typically lifted by your cranes? 10. (a) What is the average on-hook exposure? U.S. $ (b) What is the maximum on-hook exposure? U.S. $ 11. Advise if one or few industries or customers provide a large percentage of your work (i.e. Utilities, Marine, Stevedoring, Oil field, Refineries, Bridges, Commercial Construction, Industrial Plants)

3 12. (a) Do you rent equipment other than cranes? YES NO (b) What kind of equipment? (c) What are the revenues with operator? (including installation, repair, and removal) (d) What are revenues without operator? (including installation, repair, and removal) 13. Operators and oilers are Union Non-Union Number of operators Oilers All other employees 14. Do you have: YES NO a. Loss Control & Maintenance b. A formal loss control or safety plan c. Safety Manager responsible for the safety program? d. Regular safety meetings with employees? e. Screenings or reference process for new operators? f. A minimum age for operators? What age? g. A scheduled maintenance program? h. A written form for crane inspections? i. An incident report form? j. Are cranes certified? If so, how often & by whom? k. Are certificates required by lessees on bare rentals? l. Do you perform dual/tandem lifts? If so, describe the coordination controls used:

4 15. Please provide full descriptions of the last five largest jobs performed by you. Please include who you worked for, what (descriptive) you did for them and gross receipts generated Please provide a list of your 5 largest PENDING jobs. Please include who you will work for, what (descriptive) you will do for them and estimated gross receipts generated Full (5) Year Receipts/Payroll History Payroll Receipts

5 18. Schedule of Drivers and Operators (use additional page if necessary) 19. Current/Prior Carrier Information five years needed 20. Please attach: (a) List of equipment including year, make, model, serial numbers and values (b) Copy of rental contracts or work agreements, including bare rental contract (c) 5 years general liability loss runs (d) Copies of all crane certifications (e) Copies of all operator certifications (f) Copy of daily crane inspection form (g) Financials

6 SIGNED PROPOSAL FORM It is understood and agreed that the signed proposal form, by the Assured, forms part of this policy and that underwriters hereon shall rely upon the information to determine the acceptability, rates and coverage. It is further understood that any misrepresentation or omission shall constitute grounds for immediate cancellation of coverage and denial of claims, if any. It is further understood that the applicant and/or affiliated company is under a continuing obligation immediately to notify his underwriters through his broker of any material alteration to information given. All other term, clauses and conditions remain unchanged. Date: Producer: Phone #: Insured s Name & Title: Applicant s Signature:

7 CONTRACTORS EQUIPMENT SUPPLEMENTAL APPLICATION 1. Company Name: 2. Address: 3. Effective Date: Expiration Date: 4. Territory of Operations: 5. Location Address: 6. Describe Type of Security at Location: 7. Who Maintains the Equipment? 8. Who Transports Equipment from job to job? 9. Does insured use certified or trained operators and does he receive proof of experience &/or education? Yes No 10. When property is left at job sites, what precautions are taken against theft? 11. Does insured rent or lease equipment from others? Yes No 12. Is any equipment used underground? Yes No Explain: 13. Are there any operations on barges? Yes No 14. desired? 15. Does the insured bare rent their equipment? Yes No If yes, please provide a copy of bare rental agreement. 16. Does the insured transport goods of others? Yes No Limit? Gross Receipts: Items Hauled: ICC# (If cargo filing is required): 17. Does the insured warehouse goods of others? Yes No Gross Receipts: Items Stored:

8 18. Please provide list of equipment, including year, make, model, serial number, capacity and value. Use additional paper as needed. Optional Coverage: Include Boom/Overload Coverage Miscellaneous Tools ($10,000 per Loss/$500 Max per item) Rental Expense 72 Hour ($500 per day/$15,000 Aggregate) Leased/Rented Equipment from others: Limit: Latest 12 Months rental expenditures: Motor Truck Cargo Previous Insurance Carriers: Carrier Carrier Carrier Applicant Signature: Date PLEASE ATTACH THE FOLLOWING: 1. 5 YEARS LOSS RUNS 2. LIST OF EQUIPMENT INCLUDING YEAR, MAKE, MODEL, SERIAL NUMBER, CAPACITY, REACH, VALUE 3. COPY OF BARE RENTAL AGREEMENT