Fillable Crane Supplement 2) Curr (Risk Placement Services, Inc.)

Fill Online, Printable, Fillable, Blank Crane Supplement 2) Curr (Risk Placement Services, Inc.) Form

Use Fill to complete blank online RISK PLACEMENT SERVICES, INC. pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Crane Supplement 2) Curr (Risk Placement Services, Inc.)

On average this form takes 66 minutes to complete

The Crane Supplement 2) Curr (Risk Placement Services, Inc.) form is 7 pages long and contains:

  • 1 signature
  • 4 check-boxes
  • 260 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Risk Placement Services, Inc. forms online.

BROWSE RISK PLACEMENT SERVICES, INC. FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
1
Crane Supplement
1) Full Name of Insured including all owned or controlled subsidiaries:
_______________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
2) Curr
ent Mailing Address: ___________________________________________________________
3) Location Address: ___________________________________________________________
Federal ID Number: ___________________________________________________________
Applicant’s Website: ___________________________________________________________
MC Docket Number: ___________________________________________________________
4) Individual Co- Partnership Corporation Other **
** Description of Other: _____________________________________________________________
5) a) # of Years in bu
siness under the present name? __________
b) If less than 5 years, please provide (under separate attachment) a resume’ of the principal’s
applicable experience and/or previous name (s) of the company & current financials.
c) Name of person to be contacted in your organization for purpose of inspection:
Name: _________________Phone #: _____________ Email Address: _______________
6) a) What is the full geographical area of operation; % applicable by state: ______________________
_________
___________________________________________________________________
b) Please list applicable % of jobs located in major metropolitan area (s): ______%; ____N/A If
applicable, metropolitan area(s) is/are: ________________________________________
6) Eff
ective Date: ______________________
If Mid-term Replacement, please detail reasons for replacement: ______________________________
__________________________________________________________________________________
__________________________________________________________________________________
7) Description of all operations with % breakout of commercial vs. residential: _____________________
__________ ________________________________________________________________________
___________________________________________________________________________________
8) What kinds of goods/equipment are typically lifted by your cranes? ______________________________
_____ _______________________________________________________________________________
____________________________________________ or if N/A
Yes No
9) a) What is the average on-hook exposure: US $ ______________ or if N/A Yes No
b) What is the maximum on-hook exposure: US $ _______________or if N/A Yes No
2
c) Please provide details of any additional contractual transfer back to the Insured’s client:
________________________________________________________________________
____
______________________________________________________________________________
______________________________________________________________________________
10)
Please provide estimated breakdown of annual gross receipts & payroll.
Payroll Receipts
Crane Rental with Operator
Bare Crane Rentals
Contractors Equipment Rental to Others
Bridge Construction/Reconstruction
Caisson or Cofferdam Work (need specific job details)
Dam Construction/Reconstruction (need specific job details)
Docks/Piers /Pile Driving/ Jetty Breakwater Construction
Millwright Work
Iron/ Steel Erection
Steel Fabrication (AISC Member __________ (yes / no)
Concrete Erection
Rigging (if done separately)
Sale of New Equipment *
Sale of Used Equipment **
Scaffolding / Hoists
Street or Road Construction/Reconstruction
Telecommunication Construction
Sub Contractors (* see below)
Miscellaneous (describe in full)
________________
________________
________________
_______________________________________________________________________________________________
_
_______________
_
_______________
_
_______________
_
_______________
_
_______________
_
_______________
_
_______________
_
_______________
_
_______________
________________
_
_______________
_
_______________
_
_______________
________________
_
_______________
__
______________
________________
________________
__
______________
__
______________
__
______________
________________
__
______________
__
______________
__
______________
________________
__
______________
________________
__
______________
__
______________
__
______________
__
______________
__
______________
3
Please describe any installation, repair or removal work for any of the above classes:
_________________________________________________________________________________
_________________________________________________________________________________
Please advise any related association that you are a current member of: ______________________
Sub Contractor Operations & Description: ____________________________________________
Cert of Insd Required: Yes
No; Required GL Limits: $______ Primary:________
Excess/Umbrella: ________; Per Project Aggregate Endt required: Yes No
(*) New Equipment Sales:
a) Is the insured included as a Vendor and/or Additional Insured on the Mfg’s policy? Yes No
If (y
es) please provide a current Certificate of Insurance from the Mfg that shows the
inclusion of the Insured as a Vendor and/or Additional Insured
b) Does the Insured offer any Warranty(s) other than the Mfg’s Warranty Representation?
Yes No. If (yes) d
escribe in full any Warranty Representation made by the Insured
____________________________________________________________________
____________________________________________________________________
(**) Used Equipment Sales: _____________________________________________________
a) Does the Insured provide any Warranty Representation for any Used Equipment? Yes No
If (yes) please provide a complete copy of the Insured’s Warranty Representation(s).
11) A
dvise if one or a few industries/customers provide a large % of your work (ie. Utilities, Marine,
Stevedoring, Oilfield, Bridges, Commercial Construction, Industrial Plants, Governmental Entities, etc.)
_____________________________________________________________________________
_____
_________________________________________________________________________________
_ 12) a) Do you rent equipment other than cranes?
Yes No
If (yes), please describe equipment ___________________________________________________
b) Copy of rental agreement included? Yes (copy attached); No NA
c) What are the revenues with operator (includes installation, repair & removal) $ _______
d) What are the revenues without operator (includes installation, repair & removal) $ _________
e) What are your expected expenditures in rented/leased equipment from others? $
__________
13) O
perators & Oilers are _____Union _____Non-Uni
on
Number of Operators ______ Oilers _______ All Other Employees ______
Are crane operators NCCCO certified: (_______#) Yes or No
Operating in full compliance with State/s operational and/o
r licensing requirements Yes No
or describe the reasons for the non-compliance. _____________________________________________
4
14) Please advise if you have the following:
a) Loss Control & Maintenance
Copy of maintenance record specimen (attached)
Copy of maintenance record (attached) for all cranes +25 yrs old
Are equipment inspections in compliance with Local, State & Federal Regulations?
b) A formal Loss Control/Safety Plan in effect? (attach copy) Yes No
c) Safety Manager responsible for safety program? Yes No Name of Safety Manager / Phone #
_________________________________________________________________________________________
d) Regular Safety meetings conducted with employees?
e) Screening or reference process for new operators?
f) A minimum age for operators? What age? ___yrs.
Are all operators licensed/certified. If not, please explain below:
_________________________________________________________________________________
Attach list of all operators, including DOB
g) A sch
eduled maintenance program in effect?
h) A written form for crane inspections? (attach copy)
i) An
accident/ incident report form?
15) Please advise regarding the following:
a) Are cranes certified? Yes
No (If (yes) how often & by whom? _________________________
___________________________________________________________________________________
b) Ar
e insurance certificate required by Lessee on bare rentals?
* Attach copy of rental agreement herein?
c) Do y
ou perform dual/tandem lifts?
If (yes), describe the co-ordination controls used: _______________________________________
d) Are weights determined before all lifts?
e) Are outriggers fully extended & suitable soil and/or ground base checked before
use?
f) Are cranes & rigging inspected daily by the operator PRIOR to use?
g) Are mats for crawlers used?
h) Are boom angle indicators available & utilized?
i) Are load charts used for all lifts?
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
5
j) Describe overturn prevention procedure for equipment operated on barges, in culverts of cofferdams,
falsework or temporary piers? ________________________________________________________
_________________________________________________________________________________
k) Describe the communication techniques employed during these lifts:. _____________________
________________________________________________________________________________
l) Are professional engineers available to determine adequacy of equipment for lifts?
If employees, please describe herein: ______________________________________________
m) Any losses over $10,000 in the past 5 years? Yes No
n) How long are maintenance & inspection records kept? ____________________________
16) Please provide full descriptions of the five (5) largest jobs performed by you within the last 3 years. Please
include who you worked for, description of job, heights over 5 stories & the applicable receipts generated for the
job.
a) _______________
__________________________________________________________________
b) _________________________________________________________________________________
c) _______________
___________________________________________________________________
d) _______________
__________________________________________________________________
e) _______________
___________________________________________________________________
17) Please provide full descriptions of the five (5) largest jobs PENDING jobs and include who you will be
working for, description of your job, heights over 5 stories & the estimated receipts generated for the job.
a) _______________
___________________________________________________________________
b) __________________________________________________________________________________
c) _______________
___________________________________________________________________
d) _______________
___________________________________________________________________
e) _______________
___________________________________________________________________
18) Full five (5) Year Payroll/Receipts History (*) Payroll Receipts
2015-2016
2014-2015
2013-2014
2012-2013
2011-2012
__________________
__________________
__________________
__________________
__________________
6
( * Pl
ease note in applicable year of any acquisition or sell off by the Insured and describe details hereunder)
______________________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
19)
Schedule of Drivers & Operators (use additional page if necessary) Attached with submission
Name ___________________DOB ________License # _________Yrs Experience ______
Name ___________________DOB ________License # ________ Yrs Experience _____
Name ___________________DOB ________License # ________ Yrs Experience _____
Name ___________________DOB ________License # ________ Yrs Experience _____
Name ___________________DOB ________License # ________ Yrs Experience _____
20)
Current/Prior Carrier Information
Insurer: _________________Policy Term _____________Policy # ____________Limits ___________
Premium ______________ SIR/Deductible _______________Riggers Incl: Yes No
Insurer: _______________Policy Term ______________Policy # ___________ Limits _____________
Premium ______________SIR/Deductible ________________ Riggers Incl: Yes
No
Insurer: _______________Policy Term ______________Policy # ___________Limits _____________
Premium _____________ SIR/Deductible ____________ Riggers Incl: Yes No
Insurer: ______________ Policy Term ______________ Policy # ___________Limits _____________
Premium _____________ SIR/Deductible _____________Riggers Incl: Yes No
Insurer: ______________ Policy Term ______________Policy # __________Limits _____________
Premium _____________ SIR/Deductible ___________ Riggers Incl: Yes No
7
IN ORDER TO PROVIDE YOU WITH TIMELY UNDERWRITING OF THE
SUBMISSION, PLEASE INCLUDE THE FOLLOWING WITH YOUR SUBMISSION:
a) GL Acord application – signed, dated & fully completed;
b) Requires London Program Contractors Supplemental Application – signed, dated & fully
completed;
c) List of Equipment including year, make, model, serial numbers & values;
d) Specimen copy of equipment maintenance/inspection report;
e) Copy of recent crane certification for equipment >+25 years of age;
f) Copy of rental contracts or work agreements including bare rental contracts;
g) Copy of specimen job ticket;
h) Currently valued audited financials;
i) List of all operators including license #, DOB & years of experience;
j) Five (5) years currently valued (within 60 days) hard copy Carrier loss runs with specific details for
all losses at $10,000 and greater.
k) Copy of Safety Program;
l) COPIES OF EXPIRING GL AND IM/CPE POLICIES;
Signed Proposal Form: It is understood & agreed that the signed proposal form by the Assured, forms part of this
policy & that underwriters hereon shall rely upon the information to determine the acceptability, rates & coverage.
It is further understood & agreed that misrepresentation or omission may constitute grounds for immediate
cancellation of coverage & potential denial of claims if any.
It is further understood & agreed that the applicant and/or affiliated company is under a continuing obligation,
immediately to notify his/her underwriters through the insurance agent/broker of any material alteration to the
information given.
All other terms & conditions remain unchanged.
Date: ___________ Insured’s Name & Title: ___________________________________________
Applicant’s Signature: ______________________________________________________________
Producer/Agency Name: _____________________________________________________________
Phone # ___________________________ Fax # _________________________________________
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Crane Supplement 2) Curr (Risk Placement Services, Inc.)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 30 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document