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BUILDERS RISK INSURANCE (Risk Placement Services, Inc.)

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  • 6 check-boxes
  • 164 other fields

Country of origin: US
File type: PDF

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BROWSE RISK PLACEMENT SERVICES, INC. FORMS

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Please Print
or Type
Name of Applicant
Location of Yard (Exact Address)
Supplemental Application for
BUILDERS’ RISK INSURANCE
to be used with standardized industry Commercial Insurance
Applications
Applicant Information Section, Commercial General Liability Section (as
needed)
Check One:
Open Builders Risk Policy
Coverage on a Single Hull
How long has yard been in operation under present Management? Name of Operations Manager Age
Experience in This Field
No. of Full-Time Employees
No. of Part-Time
E
mployees
TYPE OF VESSELS
BUILT
(If more than one (1) location is involved, provide the following information on each — separate application
recommended)
VESSEL
MATERIALs
(Check
Below)
NO. BUILT
ANNUALLY
Steel Wood Aluminum Fiberglass Fero Cement
Deck Barges
Crane Barges
Tank Barges
Hopper Barges
Towboats
Crewboats
Supply Boats
Fishing Vessels
How
many vessels expected to be under construction at any one time:
Inside: Outside:
Maximum exposure anticipated at any one time:
Inside: Outside:
Any One Vessel:
$ Avg. Value $ Max. Value
M
inimum distance between vessels:
Inside
: Outside:
Maximum foreseeable loss by fire:
Inside: Outside:
Any Conversions? (If “yes,” give number annually)
Yes No
COVERAGE FOR ONE SPECIFIC VESSEL
If application is for Builders Risk Coverage on one (1) specific vessel, complete the following:
Type of Vessel New Construction
Conversion or Reconstruction
Dimensions
Hull Materials
Completed Contract Price
$
Period of Construction
From: To:
Construction Site (Same as location of yard above)
Describe Extent of Trials
Delivery Location
LAUNCHING AND TRIAL TIPS
Describe Method of Launch Trial trips are confined to within:
Miles of Yard
Where does fitting out take place? How many vessels fitting out at any one time?
If delivery to owner is other than at yard, describe: Any Towing? Outside Port Area?
Yes No Yes No
Describe Extent of Trails (Hours of trial operation, number of crew, usual number of customers aboard, etc.)
Public Fire Department
Paid Volunteer
FIRE
PROTECTION
Public Fire Hydrants Public Fire Mains
How many? How Far Distant? Size: Pressure:
Private Fire Protection (If “yes,” describe)
Yes No
SECURITY
How Many Watchman Employed? How Many on Each Shift? Watchlocks?
Yes No
Is yard fenced in, with guard at gate, when yard is operating?
Yes No
How long has shipyard been in operation under present management? (Give prior business name, if any)
Describe construction of all buildings in which vessels are built
Describe extent of any past flooding
Describe any other commercial activities at this yard
VESSEL CONSTRUCTION
Is any vessel work subcontracted? (If “yes,” describe) If “yes,” are certificates of insurance required?
Yes No Yes No
Applicant’s gross receipts for past 3 years derived from vessel construction:
$ YR $
YR $ YR
Are vessels under construction financed? (If “yes,” name with whom)
Yes No
Current Line of Credit
$
Is release secured limiting liability? (If “yes,” give amount)
Yes No $
INSURANCE
REQUESTED
AMOUNT OF INSURANCE
Per Vessel
$
Pre-Keel Coverage
$
Per Occurrence
$
Deductible
$
Third Party protection and indemnity coverage is available. If desired, indicate limit of liability
requested: $
General Comments or Special Insurance Conditions you require:
To be supplied by Agent if Known
HIGHEST CO—INSURANCE FIRE CONTENTS RATE
Desired Effective Date
PREMISES
BUILDING #
BUILDING #
BUILDING #
Construction Type
Construction Type
Construction Type
A.
B.
C.
LOSS
EXPERIENCE
Please attach loss experience for the past 5 years with amounts paid and outstanding (including uninsured losses). Loss
runs from prior carriers are preferred.
REMARKS
Use this section for additional space to answer any “yes” questions or to give any other relevant information
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.
I understand that the above information, which is correct and complete to the best of my knowledge, is to be the basis of
insurance, if granted, but does not obligate me to accept the insurance, nor the Company to accept the risk.
Signature of Applicant Date
Title
Agent Date
Agent’s Address
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BUILDERS RISK INSURANCE (Risk Placement Services, Inc.)

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Completed 30 July 2020

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