CONTRACTORS EQUIPMENT APPLICATION
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1 CONTRACTORS EQUIPMENT APPLICATION 1. Name of Applicant: 2. Mailing Address: Location Address: Website Address: 3. Proposed Policy Term: From: To: 4. Annual Income Last Year: Estimated Current Year: 5. Applicant s Business: Number of Years in Business: 6. Contact Name for Inspection: Telephone Number: Address: General Information ANSWER ALL QUESTIONS IF THEY DO NOT APPLY, INDICATE NOT APPLICABLE. 7. Have you declared bankruptcy or been in receivership within the past five years?... Yes No 8. Describe the location and types of projects including the terrain and conditions where the equipment is usually operated: 9. Provide detail of operations if equipment is used underground, underwater or on watercraft: 10. Are any preventive maintenance procedures provided for the Contractor s equipment?... Yes No If yes: a. How often is equipment serviced? b. Who services the equipment? 11. Is contractor s equipment equipped with tracking devices, such as GPS, etc.?... Yes No If yes, provide type of equipment: 12. Are bulldozers, loaders, backhoes equipped with: Locking gas caps?... Yes No Anti theft devices?... Yes No Any Other?... Yes No If yes, explain: 13. Are fire extinguishers present on every piece of equipment?... Yes No 14. Will equipment be used: a. In water on barges?... Yes No b. Near water (bridge/dam/levee work)?... Yes No WHI APP (02-13) Page 1 of 5
2 15. Is a guard or watchperson service employed where the equipment is operated or stored?... Yes No 16. Are all employees (including temporaries) trained to handle the equipment they will operate?... Yes No 17. At the job and storage sites: a. Is there security lighting?... Yes No b. Are the sites fenced?... Yes No c. Are there any hazardous or flammable materials stored in close proximity to the equipment?... Yes No d. Are any of the permanent storage areas subject to flooding?... Yes No 18. Is any of the equipment stored indoors?... Yes No If yes: a. Is the storage site equipped with a recognized approved central station fire alarm system and fire extinguishers?... Yes No b. Is the storage site or any portion of the site equipped with a sprinkler system?... Yes No c. Are no-smoking rules posted and enforced?... Yes No d. Are recognized approved central station burglar alarms installed and maintained?... Yes No 19. At the site where the equipment is stored: a. What is the Public Protection Class (PPC) rating? b. Are there any private protection improvements?... Yes No c. What is the distance in feet to the nearest fire hydrant?... feet d. What is the distance in miles to the nearest responding fire department?... miles 20. Is the equipment safety-inspected at regular intervals?... Yes No 21. Are the transporting vehicle and tie down equipment checked out before use?... Yes No Coverages Requested 22. Schedule of Equipment: a. Excluding Cranes Item Model Year Type Unit, Manufacturer, Model, Capacity Serial Date Purchased New/ Used Purchase Price Amount of Insurance WHI APP (02-13) Page 2 of 5
3 b. Cranes Rig Type MFG Item Model Year Model Capacity/Carriage Wheel or Track (Conventional Hydraulic Hydro) & JIB Length Serial Date Purchased & JIB-Length Purchase Price Amount of Insurance Blanket Equipment Limit:... All Covered Property in Any One Occurrence Limit:... Deductible:... c. List any loss payees needed on above equipment Loss Payees 23. Does applicant own any equipment on which insurance is not currently being sought?... Yes No If yes, explain why insurance is not being purchased: WHI APP (02-13) Page 3 of 5
4 24. Do you lease, rent or borrow equipment from others?... Yes No Maximum value of leased, rented or borrowed equipment at any one time Maximum value for any one item: Cost of Leasing or renting: Type of equipment rented or leased: Type of equipment borrowed: Average Time Period Rental: Average value of leased, rented or borrowed equipment at any one time Number of Times Rented Per Year: 25. Do you lease or rent equipment to others?... Yes No When do you conduct background or credit checks? Do you have a lease or rental agreement for every rental?... Yes No (A copy of the rental agreement may be required.) Do you provide instructions to renters to ensure they are familiar with the operation of the equipment?.. Yes No Do you rent only to professional contractors?... Yes No Please describe the equipment: Receipts from rental or leasing of equipment: 26. Do you loan or borrow equipment to others?... Yes No Optional Coverages Optional Coverages Limits of Insurance Deductibles Tools and Clothing Belonging to Your Employees Miscellaneous Items Blanket Coverage Rental Reimbursement Per Employee Per Any One Loss Per Item Per Any One Loss Per Day Per Any One Loss 27. Prior Carrier and Loss Experience Summary (must be completed): Provide prior insurance carriers during the last three years: Provide information regarding the date, cause and amount of all losses during the last three years whether covered or not covered by insurance: Loss Date Equipment Damaged and Cause of Loss Amount Paid/Pending 28. Additional Information Provide list of any additional information attached with the application: WHI APP (02-13) Page 4 of 5
5 This application does not bind the applicant or the Company to an agreement. However, the information stated on the application shall be the basis of the contract should a policy be issued. The application does not provide coverage or limits and may reflect different coverages or limits than offered by the Company. FRAUD WARNINGS: Attach completed WHI APP-152, State Fraud Notification Compliance form. APPLICANT S NAME AND TITLE: APPLICANT S SIGNATURE: PRODUCER S NAME: PRODUCER S SIGNATURE: (Must be signed by an active owner, partner or executive officer) CONTACT PERSON: CONTACT PERSON S PHONE NUMBER: WHI APP (02-13) Page 5 of 5
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