Fillable CONTRACTORS EQUIPMENT SUPPLEMENTAL APPLICATION (Kinsale Insurance)

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CONTRACTORS EQUIPMENT SUPPLEMENTAL APPLICATION (Kinsale Insurance)

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Page 1 of 6
CONTRACTORS EQUIPMENT – SUPPLEMENTAL APPLICATION
ATTACH ADDITIONAL SHEETS AS NECESSARY.
ANSWER ALL QUESTIONS. If not applicable, indicate N/A.
1)
Named Insured:
Brokerage/Broker:
New Venture?
Yes No
Renewal?
Yes No
Policy Number:
Current Effective Date:
Current Expiry Date:
Requested Effective Date:
Requested Expiry Date:
Website:
2) Current Carrier Information:
Expiry Date:
Yes No
Please attach copies of the following:
a) Currently valued five-year loss runs, including complete claim details for all losses
b) Applicant’s description of operations, brochure, or marketing materials if a website is not available
3) Mailing Address:
City: State: Zip Code:
4) Are you a(n): Corporation Individual Partnership Municipality For Profit
Joint Venture Other:
5) How long have you been in operation under this business name or any others (please provide any prior entities or
additional entities/DBAs to be covered)?
6) Blanket Limit requested:
7) Any One Occurrence Limit requested:
8) Deductible requested:
I. GENERAL INFORMATION
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 6
9) If you have any Loss Payees to be scheduled, please complete the following:
Name
Street Address
Applicable Equipment Serial Numbers
10) Please complete the following table for your receipts and payroll:
Revenue
Payroll
Projected Year
Last 12 Months
2nd Prior Year
11) Do you loan or rent equipment to others? If yes, please complete section III: RENTALS. Yes No
12) Is any equipment loaned or rented from others to you? Yes No
a. If yes, what are your total rental expenditures the last 12 months?
b. What are your projected rental expenditures for the coming year?
c. Are you contractually required to insure this equipment against damage or loss? Yes No
If yes, include this equipment in 13) below unless such equipment is insured elsewhere.
13) Please complete the following regarding requested Scheduled Equipment (attach additional sheet if necessary):
Make and Model
Type and
Capacity
Serial Number
or VIN
Date
Purchased
Date of
Manufacture/Age
Purchase Price
Requested
Insured Value
14) Are all employees, including any temporary or seasonal hires, trained to handle the equipment Yes No
they will operate? If no, please attach an explanation.
II. OPERATIONS
Page 3 of 6
15) Do you have a written employee handbook or formal safety guidelines? Yes No
a. How frequently are safety meetings held?
16) How is equipment transported to job sites?
Own vehicles/Driven Common Carrier Other:
17) Will equipment be used near water, including on bridges, dams, and levees, or on barges? Yes No
a. If yes, please attach details.
b. Will equipment be used on bridges or overpasses not over or near water? Yes No
18) Will equipment be used underground, including in mining operations? If yes, please attach details. Yes No
19) Is equipment rental, leasing, or rent to own your sole operation? Yes No
20) Is all of your equipment scheduled in 13) available for rental, lease, or loan to others? Yes No
a. If no, what equipment is not available to others?
21) Do you provide rentals with operators? Yes No
22) Do you have a written rental contract, lease agreement, or loan agreement in place before Yes No
releasing any equipment to a lessee/borrower? If no, please attach an explanation.
a. Are lessees required to insure the equipment against loss or damage for the insured value Yes No
of the equipment for the entire duration of the rental? If no, please attach an explanation.
b. Do all contracts or agreements contain a hold harmless clause in your favor? Yes No
c. Do you collect certificates of insurance from lessees? Yes No
d. Do you allow subleasing of equipment? Yes No
e. Does the contracts or agreements stipulate required minimum security measures Yes No
when equipment is not in use and appropriate lock-out procedures? If no, please
attach an explanation.
23) What security measures are in place at the storage location(s)? Check all that apply:
Security Lighting Locked Fencing Locked Garages Premise Cameras
Security Guards Other:
24) What security measures are in place at job site location(s)? Check all that apply:
Security Lighting Locked Fencing Security Guards Off-site Garaging
Other:
25) How frequently is equipment inspected?
26) How frequently is equipment given routine maintenance?
27) Is all equipment tracked with a GPS, LoJack, remote disable, or similar device? Yes No
28) Are all bulldozers, loaders, cranes, and backhoes equipped with the following:
a. Locking gas caps? Yes No
b. Anti-theft devices? Yes No
c. Additional deterrent devices: Yes No
III. RENTALS (complete only if you are renting equipment to others)
IV. EQUIPMENT SECURITY
Page 4 of 6
29) Are fire extinguishers present on or in all equipment? Yes No
a. If no, please attach an explanation.
b. How frequently are extinguishers charged or replaced?
c. Does any equipment have automatic fire suppression systems installed? Yes No
d. If yes to c., which equipment?
30) Is any equipment stored in areas subject to flooding or wildfire? Yes No
a. If yes, please attach details as to how these risks are mitigated.
31) Do you know of any incidents not currently reported to insurance that may result in a claim Yes No
against you? If yes, please attach an explanation.
32) During the past five years, has any insurer ever canceled or non-renewed similar insurance Yes No
to any applicant or has your insurance been canceled for nonpayment of premium by any
insurance or finance company? If yes, please attach an explanation.
33) Claim Details (duplicate this page for all claims):
a. What was the date of the incident?
b. What line(s) of your coverage(s) was this claim reported on? Check all that apply:
Contractors Equipment Contractors Equipment Rental Commercial Auto - Liability
Commercial General Liability Transportation Pollution Liability Commercial Auto – Phys. Damage
Uninsured/Self Insured Other:
c. Please describe the circumstances leading up to the claim, the factual details of the incident, the equipment lost
or damaged, and steps taken following the incident to mitigate loss and evaluate the claim. Please note
“attached” and include an additional sheet if the details do not fit below:
d. If this claim is closed, did it require trial or arbitration to settle? Yes No
e. If this claim is open, do you anticipate it going to trial or arbitration? Yes No
+ If yes, when?
f. Were any of your procedures or rules changed after this incident? Yes No
g. Was the equipment a total loss/full insured value claimed? Yes No
+ If no, has the equipment been repaired and returned to service? Yes No
h. Total claimed: $
FRAUD WARNING
NOTICE TO ALABAMA, ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, CONNECTICUT, DELAWARE, GEORGIA, IDAHO, ILLINOIS, INDIANA, IOWA, KANSAS,
MARYLAND, MASSACHUSETTS, MICHIGAN, MINNESOTA, MISSISSIPPI, MISSOURI, MONTANA, NEBRASKA, NEVADA, NEW HAMPSHIRE, NORTH CAROLINA,
NORTH DAKOTA, OREGON, RHODE ISLAND, SOUTH CAROLINA, SOUTH DAKOTA, TEXAS, UTAH, VERMONT, WASHINGTON, WEST VIRGINIA, WISCONSIN,
AND WYOMING APPLICANTS: In some states, 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, for the purpose of misleading, conceals information
concerning any fact material thereto, may commit a fraudulent insurance act which is a crime in many states.
V. CLAIMS HISTORY
Page 5 of 6
NOTICE TO COLORADO APPLICANTS: 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 policy holder or
claimant for the purpose of defrauding or attempting to defraud the policyholder or claiming with regard to a settlement or award payable for insurance
proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of
defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, 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 insurance company files a statement of
claim containing any false, incomplete or misleading information is guilty of a felony of the third degree.
NOTICE TO HAWAII APPLICANTS: 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 KENTUCKY 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.
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.
NOTICE TO MAINE APPLICANTS: 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 denial of insurance benefits.
NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to
criminal and civil penalties.
NOTICE TO NEW MEXICO 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 civil fines and criminal penalties.
NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud an 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 $5,000 and the stated value
of the claim for each such violation.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he/she 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.
NOTICE TO OKLAHOMA APPLICANTS: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes a any claim
for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
NOTICE TO PENNSYLVANIA APPLICANTS: Any person who knowingly and with intent to defraud any insurance company, or other person, files an application
for insurance or statement of a 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 subjects the person to criminal and civil penalties.
NOTICE TO TENNESSEE APPLICANTS: 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.
NOTICE TO VIRGINIA APPLICANTS: 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.
The Applicant acknowledges that the answers provided herein are based on a reasonable inquiry and/or investigation. The Applicant warrants that the
above statements and particulars together with any attached or appended documents are true and complete and do not misrepresent, misstate or omit
any material facts.
The Applicant agrees to notify us of any material changes in the answers to the questions on this questionnaire which may arise prior to the effective
date of any policy issued pursuant to this questionnaire and the Applicant understands that any outstanding quotations may be modified or withdrawn
based upon such changes at our sole discretion.
Completion of this form does not bind coverage. Applicant’s acceptance of the company’s quotation is required prior to binding coverage and policy
issuance.
Page 6 of 6
All written statements and materials furnished to the company in conjunction with this application are hereby incorporated by reference into this
application and made a part of this application.
Applicant: Title:
FEIN #:
Applicant’s Signature: Date:
Agent/Broker Name:
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CONTRACTORS EQUIPMENT SUPPLEMENTAL APPLICATION (Kinsale Insurance)

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Completed 31 January 2021

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