Fillable EG Hydroelectric Supplemental Application (Kinsale Insurance)

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EG Hydroelectric Supplemental Application (Kinsale Insurance)

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  • 83 check-boxes
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Page 1 of 6
HYDROELECTRIC SUPPLEMENTAL APPLICATION
COMPLETE IN ADDITION TO ACORD APPLICATIONS.
ATTACH ADDITIONAL SHEETS AS NECESSARY.
ANSWER ALL QUESTIONS. If not applicable, indicate N/A.
1)
Named Insured:
Project Name:
Brokerage/Broker:
Agency/Agent:
Renewal?
Yes No
Policy Number:
Effective Date:
Website:
2) Current Carrier Information:
Carrier:
Limit of Insurance:
Deductible:
Premium:
Offering renewal?
Yes No
Claims made?
Yes No Retroactive date:
Please attach copies of the following:
a) Currently valued five year loss runs, including claim detail for all losses open or exceeding $15,000
3) Mailing Address:
City: State: Zip Code:
4) Your premise address (if different from above):
City: State: Zip Code:
5) Please indicate your operations:
Owner/Developer Owner/Operator
General Contractor Contract Operator
Other:
GENERAL INFORMATION
OPERATIONS
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 6
6) Is the facility: Run of River Diversion Impoundment Pump Storage
7) Project is: Urban Rural Remote
8) Annual power sales: $______________ Annual production: _______________KWH Rated capacity: __________MW
9) Is the project operated/maintained by: You OR Others?
10) Is the project: Manned OR Unmanned?
a. If unmanned, frequency of visits is: Daily Weekly Monthly
b. Is there automatic notification to supervisor in the event of an emergency? Yes No
11) Dam or diversion
a. Does the project include a Dam OR Diversion?
b. Dam:
i. Is it Owned OR Leased?
If leased, who is the owner?
ii. Type of dam: concrete gravity timber crib arch embankment
buttress Other____________
iii. Size: length: __________ height: __________ width: __________
iv. Year built: _________
v. Reservoir capacity: __________ acre-feet
vi. Are flashboards used? Yes No
If yes, are they mechanical or wooden?
12) If Check all applicable protective devices for this project:
Over speed trip Reverse current Lightning protection
Over current trip High vibration Loss of excitation
Ground fault trip Low lube oil Wicket gate protection
13) Has a FERC inspection been performed recently? Yes No
(Please provide a copy of the inspection report if available.)
14) Are there any dams, reservoirs, or other hydroelectric facilities upstream Yes No
that can affect your operation? If yes, please describe:
15) What structures, (residential areas, mobile homes, or commercial areas), are located downstream from the
hydroelectric plant, and how far away are they located?
16) Are the banks of the river tall enough downstream to contain all of the water in Yes No
case of a total water containment failure?
17) Do you have a written emergency action plan? Yes No
UPSTREAM/DOWNSTREAM INFORMATION
Page 3 of 6
18) If you are hiring subcontractors, please clarify the following:
a. Do you usually hire the same subcontractors? Yes No
b. Are subcontractors always insured? Yes No
If yes, what General Liability limits do you require subs to carry?
c. Do you obtain certificates of insurance from all subcontractors? Yes No
d. Are you named as an Additional Insured on all subcontractors’ policies? Yes No
e. Do you have a written contract with your subcontractors? Yes No
f. Do all contracts contain a Hold Harmless clause in your favor? Yes No
g. Do you use any leased employees? Yes No
If yes, are you responsible for providing Worker’s Compensation for Yes No
these employees?
h. Do you carry Worker’s Compensation insurance? Yes No
19) Powerhouse:
a. Year Built:
b. Has the powerhouse been refurbished? Yes No
When?
20) Turbine(s):
a. Turbine 1 Turbine 2 Turbine 3
Type: Pelton Pelton Pelton
Kaplan Kaplan Kaplan
Francis Francis Francis
Bulb Bulb Bulb
b. Year Built:
i. Turbine 1:
ii. Turbine 2:
iii. Turbine 3:
c. If rebuilt, year of rebuild:
i. Turbine 1:
ii. Turbine 2:
iii. Turbine 3:
21) Generator(s):
a. Generator 1 Generator 2 Generator 3
Type: Synchronous Synchronous Synchronous
Induction Induction Induction
b. RPMs:
i. Generator 1:
ii. Generator 2:
iii. Generator 3:
c. Size:
i. Generator 1:
ii. Generator 2:
iii. Generator 3:
SUBCONTRACTORS
FACILITY INFORMATION
Page 4 of 6
d. Year Built:
i. Generator 1:
ii. Generator 2:
iii. Generator 3:
e. If rebuilt, year and contractor of rebuild:
i. Generator 1:
ii. Generator 2:
iii. Generator 3:
22) Transmission and Distribution:
a. Size of Transformer 1:
b. Size of Transformer 2:
c. Size of Transformer 3:
d. Do you own transmission lines? Yes No
If yes, how long is it?
23) Penstock:
a. Is the Penstocck above ground OR underground?
b. Type: Steel Concrete Other
24) Is the site secured with fences, locked gates or other physical barriers? Yes No
25) Are there hazard warning signs at the premises? Yes No
26) Is the public allowed access to the premises? Yes No
27) Are there any recreational facilities on or adjacent to your premises? Yes No
28) Has any lawsuit ever been filed, or any claim otherwise been made against your company Yes No
or any partnership or joint venture of which you have been a member or your company’s
predecessors in business, or against any person, company or entities on whose behalf
your company has performed operations or assumed liability? For the purpose of this
application only, a claim means a receipt of a demand for money, service or arbitration. If
Yes, please attach an explanation including the name(s) of the person, company or entity
and the name(s) and location(s) of the projects where such operations were performed.
29) Is your company aware of any occurrences, facts, circumstances, incidents, situations, Yes No
damages accidents, (including but not limited to allegations of faulty or defective
workmanship, product failure, construction dispute, property damage or construction
work injury) at a location or project where your company has performed operations that
a reasonably prudent person might expect to give rise to a claim or lawsuit whether valid
or not which might directly or indirectly involve the company? If Yes, please attach an
explanation including the name(s) and location(s) of the projects where such operations
were performed.
OTHER
Page 5 of 6
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.
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.
Page 6 of 6
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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EG Hydroelectric Supplemental Application (Kinsale Insurance)

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Completed 16 July 2020

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