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CRANE AND RIGGERS SUPPLEMENTAL APPLICATION (Kinsale Insurance)

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Page 1 of 7
CRANE AND RIGGERS – 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
c) Copies of any OSHA violation reports and details about subsequent procedural remediation
d) Copies of all training manuals and employee handbooks
3) Mailing Address:
City: State: Zip Code:
4) What are your operations? Check all that apply and provide a revenue percentage for each applicable:
Crane Rental – With Operator % Crane Rental – Without Operator %
Rigging – Not Part of Crane Ops % Millwright/Machinery Installation %
Equipment Sales – New % Equipment Sales – Used %
Hoist Rental – With Operator % Hoist Rental – Without Operator %
Equipment Rental other than Cranes or Hoists – With Operator %
Equipment Rental other than Cranes or Hoists – Without Operator %
Steel Erection % Crane Inspection Services %
Other: % Other: %
I. GENERAL INFORMATION
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 7
5) Are you a(n): Corporation Individual Partnership Municipality For Profit
Joint Venture Other:
6) 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)?
7) Please complete the following table for your receipts and payroll:
Operations
Payroll
Projected Year
Gross Receipt
Projected Year
Payroll
Last 12 Months
Gross Receipt
Last 12 Months
Crane Rental – With
Operator
Crane Rental –
Without Operator
Rigging – Not Part of
Crane Ops
Millwright/Machinery
Installation
Equipment Sales –
New
Equipment Sales –
Used
Hoist Rental – With
Operator
Hoist Rental –
Without Operator
Equipment Rental
other than Cranes or
Hoists –
With Operator
Equipment Rental
other than Cranes or
Hoists – Without
Operator
Steel Erection
Other:
Other:
TOTAL:
8) What industries do you have operations in? Check all that apply and provide a percentage for each applicable:
Utilities % Bridges %
Marine % Construction %
Stevedoring % Steel Erection %
Oilfield/Refineries % Solar Panels %
Industrial Plants % Wind Farms %
Other: % Other: %
Page 3 of 7
9) What is the average on-hook exposure?
10) What is the maximum on-hook exposure?
11) What is the typical lift weight?
12) What is the maximum lift height you will perform?
13) On average, how many jobs do you have annually?
a. What is the typical job duration?
b. How many jobs are currently in progress?
c. Do you have any jobs outside of the USA? Yes No
d. If yes to c., where?
14) Please complete the following regarding your five largest jobs in the last five years, excluding any currently ongoing
projects:
Client
Dates of Job (MM/YY)
Brief Description
15) Please complete the following regarding your five largest jobs currently underway or planned to begin within the next
twelve months:
Client
Dates of Job (MM/YY)
Brief Description
16) Do you have any work offshore? Yes No
a. If yes, is this the majority of your operations? Yes No
b. If yes, please clarify. Attach details if necessary:
17) Do you have any work that is partially or fully submerged other than offshore work, including Yes No
any work in wetlands, swamps or marshes?
a. If yes, please clarify. Attach details if necessary:
18) Do you perform any bridge, dam, or overpass work? Yes No
a. If yes, please clarify. Attach details if necessary:
19) Do you perform any blasting, demolition, mining, or wrecking operations? Yes No
a. If yes and you are blasting using explosives, do you store blasting agents? Yes No
b. If yes to a., are blasting agents stored in compliance with all applicable federal and state Yes No
regulations with access limited to licensed or approved persons only?
Page 4 of 7
c. Please attach details about these jobs.
20) Do you utilize subcontractors for any part of your operations? Yes No
a. If yes, for what?
21) For bare rentals, do you have a written rental contract, lease agreement, or loan agreement Yes No
in place before 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.
22) If you are engaging in crane inspection services, are you licensed in your state for Yes No
these operations?
23) Are all crane operators Union? Yes No
a. Are all Union operators International Union of Operating Engineers (IUOE)? Yes No
b. If no to a., to what Union do they belong?
c. How often do you refer to the Union for new or temporary hires?
d. If no to 23), please attach details about your screening and hiring process.
24) Are all crane operators required to have completed and passed an operational/field test using Yes No
the type of crane being used on a job before being assigned to that job?
25) Are all new hires required to pass a written exam testing the use of hand signals, charting of Yes No
loads and radius of use before they are allowed to operate equipment?
26) How frequently is safety and procedural training done after initial hire training?
a. Are your safety rules clearly written and available in each operators’ respective most Yes No
proficient language(s)?
b. Do training intervals change after the first full year of employment? Yes No
c. If yes to b., please clarify:
d. Do you document when each employee has training? Yes No
27) Who is responsible for determining load weights?
a. If this information is not included in your training manual or employee handbook, what is your procedure for
determining load weight?
28) Do you pre-engineer lifts? Yes No
a. If no, who engineers your lifts?
29) Do you do any jobs which require tandem/dual crane lifts? Yes No
a. If yes, please attach details about these jobs and the coordination controls used.
b. Do you have dedicated operator teams who work together on lifts? Yes No
II. OPERATOR INFORMATION (complete only if you have operator exposures)
Page 5 of 7
30) Do you perform pre-employment drug and alcohol screening? Yes No
a. Do you perform post-accident drug and alcohol screening? Yes No
b. Do you require annual physical exams? Yes No
c. If no to any of the above, please attach an explanation.
31) Is all equipment inspected and serviced by persons licensed to do so? Yes No
a. If no, please attach an explanation.
b. Is inspection and maintenance performed by your employees? Yes No
c. Are written records of inspections and maintenance logs kept for no less than five years? Yes No
d. How frequently does equipment undergo routine maintenance?
32) Are all cranes certified? Yes No
a. If no, please attach an explanation.
b. How frequently are they recertified?
c. Are load charts posted in all crane cabs? Yes No
d. Is the crane level before each lift is made? Yes No
33) Is your equipment/vehicle storage site:
a. Fenced? Yes No
b. Lighted? Yes No
c. Locked? Yes No
d. Security guards or night watchmen? Yes No
d. Other security: Yes No
34) Are firm foundations such as steel pads under outriggers for each lift? Yes No
35) Are operators required to confirm that all safety devices are operational prior to each lift? Yes No
36) Is all equipment equipped with a charged, operational fire extinguisher? Yes No
a. If no, does all equipment have built-in automatic fire suppression systems? Yes No
b. Do you have written cool-down procedures that must be followed before equipment Yes No
is left for the evening?
37) Do you use a written accident reporting form? Yes No
38) Are your accident reporting procedures compliant with all applicable NHTSA, state DOT, Yes No
OSHA, EPA or DOE incident reporting requirements?
39) 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.
40) 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.
III. EQUIPMENT INFORMATION
IV. CLAIMS HISTORY
Page 6 of 7
41) Claim Details (duplicate this section 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:
Crane and Rigger Liability Crane and Rigger Property Commercial Auto - Liability
Mechanical Breakdown Other Commercial Property Commercial Auto – Physical Damage
Commercial General Liability Pollution Legal Liability Other:
c. Please describe the circumstances leading up to the claim, the factual details of the incident, the value of
materials lost or damage to structure, 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 structure or materials a total loss/full insured value claimed? Yes No
+ If no, what percentage was lost? %
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.
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.
Page 7 of 7
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.
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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CRANE AND RIGGERS SUPPLEMENTAL APPLICATION (Kinsale Insurance)

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Completed 31 January 2021

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