Fillable CONTRACTORS EQUIPMENT APPLICATION (RT Specialty)

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CONTRACTORS EQUIPMENT APPLICATION (RT Specialty)

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The CONTRACTORS EQUIPMENT APPLICATION (RT Specialty) form is 6 pages long and contains:

  • 2 signatures
  • 8 check-boxes
  • 256 other fields

Country of origin: US
File type: PDF

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National Casualty Company
Home Office: Madison, Wisconsin
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
Scottsdale Indemnity Company
Home Office: One Nationwide Plaza
Columbus, Ohio 43215
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
Scottsdale Insurance Company
Home Office: One Nationwide Plaza
Columbus, Ohio 43215
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
Scottsdale Surplus Lines Insurance Company
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
1-800-423-7675 • Fax (480) 483-6752
www.scottsdaleins.com
CONTRACTORS EQUIPMENT APPLICATION
1. Name of Applicant:
2. Mailing Address:
Location Address:
Web Site 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:
E-mail Address:
ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE.”
General Information
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 or 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:
IM-APP-9 (4-11) Page 1 of 6
Submit Application
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
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. If this is a reporting form policy, check the box indicating the values reported include the values of
leased or rented equipment. ........................................................................................................................
Yes No
23 Schedule of Equipment:
a. Excluding Cranes
Item
No.
Model
Year
Type Unit,
Manufacturer,
Model, Capacity
Serial No.
Date
Purchased
New/
Used
Purchase
Price
Amount of
Insurance
$
$
$
$
$
$
$
$
IM-APP-9 (4-11) Page 2 of 6
Excluding Cranes (Continued)
Item
No.
Model
Year
Type Unit,
Manufacturer,
Model, Capacity
Serial No.
Date
Purchased
New/
Used
Purchase
Price
Amount of
Insurance
$
$
$
$
$
$
$
$
$
$
b. Cranes
Item
No.
Model
Year
Rig Type—MFG—
Model—
Capacity/Carriage—
Wheel or Track
Boom(Conventional
—Hydraulic—Hydro)
Boom & JIB—Length
Serial No.
Date
Purchased
New (N)/
Used (U)
Purchase
Price
Amount of
Insurance
Base
Unit
$ $
Boom
JIB Ac-
cess
TOTAL
Base
Unit
$ $
Boom
JIB Ac-
cess
TOTAL
Base
Unit
$ $
Boom
JIB Ac-
cess
TOTAL
Blanket Equipment Limit: ............................................................................................................... $
All Covered Property in Any One Occurrence Limit: ..................................................................... $
Deductible: ..................................................................................................................................... $
IM-APP-9 (4-11) Page 3 of 6
c. List any loss payees needed on above equipment
No: Loss Payees
24. Does applicant own any equipment on which insurance is not currently being sought? .......................... Yes No
If yes, explain why insurance is not being purchased:
25. Optional Coverages (check boxes that apply):
Equipment Leased/Rented or Borrowed from Others (for less than twelve [12] months)
Limit: Any 1 crane $
Any other
items
$ Aggregate $
Deductible: $
Reporting Non-Reporting
Cost of Leasing: $
Average Time
Period Rental:
Number of Times
Rented Per Year:
Type of equipment leased:
Total values of equipment borrowed (on average at any one time):
$
Type of equipment borrowed:
Optional Coverages Limits of Insurance Deductibles
Tools and Clothing Belonging
to Your Employees
$
Per Employee $
$
Per Any One Loss
$
Miscellaneous Items Blanket
Coverage
$
Per Item $
$
Per Any One Loss
$
Rental Reimbursement
$
Per Day
$
Per Any One Loss
26 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
$
$
$
27. Additional Information
Provide list of any additional information attached with the application:
IM-APP-9 (4-11) Page 4 of 6
This application does not bind YOU or US to complete the insurance, but it is agreed that the information contained herein
shall be the basis of the contract should a policy be issued.
FRAUD WARNINGS:
FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance or statement of claim 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 and sub-
jects such person to criminal and civil penalties. Not applicable in Nebraska, Oregon and Vermont.
NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or infor-
mation 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 policy holder or claimant for the
purpose of defrauding or attempting to defraud the policy holder 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.
WARNING TO DISTRICT OF COLUMBIA APPLICANTS: It is a crime to provide false or misleading information to an in-
surer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addi-
tion, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.
NOTICE TO FLORIDA APPLICANTS: 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 in
the third degree.
NOTICE TO MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an in-
surance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of in-
surance benefits.
APPLICABLE IN HAWAII: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim
for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both.
NOTICE TO LOUISIANA APPLICANTS: 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.
FRAUD WARNING (APPLICABLE IN MAINE): It is a crime to knowingly provide false, incomplete or misleading infor-
mation to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or
a denial of insurance benefits.
NOTICE TO MARYLAND APPLICANTS: Any person who knowingly and willfully presents a false or fraudulent claim for
payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty
of a crime and may be subject to fines and confinement in prison.
NOTICE TO MINNESOTA APPLICANTS: A person who files a claim with intent to defraud or helps commit a fraud against
an insurer is guilty of a crime.
NOTICE TO OHIO APPLICANTS: Any person who knowingly and with intent to defraud any insurance company files an
application for insurance or statement of claim 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 and sub-
jects such person to criminal and civil penalties.
NOTICE TO OKLAHOMA APPLICANTS: Any person who knowingly, and with intent to injure, defraud or deceive any in-
surer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information
is guilty of a felony
NOTICE TO RHODE ISLAND APPLICANTS: 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.
IM-APP-9 (4-11) Page 5 of 6
FRAUD WARNING (APPLICABLE IN TENNESSEE, VIRGINIA AND WASHINGTON): It is a crime to knowingly provide
false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties
include imprisonment, fines, and denial of insurance benefits.
FRAUD WARNING APPLICABLE IN THE STATE OF NEW YORK: Any person who knowingly and with intent to defraud
any insurance company or other person files an application for insurance or statement of claim 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, 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.
Applicant or authorized representative of the applicant, acknowledge all of the above statements are true and accurate
representations.
APPLICANT’S NAME AND TITLE:
APPLICANT’S SIGNATURE: DATE:
(Must be signed by an active owner, partner or executive officer)
PRODUCER’S SIGNATURE: DATE:
AGENT NAME: AGENT LICENSE NUMBER:
(Applicable to Florida Agents Only)
IOWA LICENSED AGENT:
IM-APP-9 (4-11) Page 6 of 6
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CONTRACTORS EQUIPMENT APPLICATION (RT Specialty)

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Completed 13 December 2020

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