Fillable EG Wind Energy Contractors Supplemental Application (Kinsale Insurance)

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EG Wind Energy Contractors Supplemental Application (Kinsale Insurance)

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The EG Wind Energy Contractors Supplemental Application (Kinsale Insurance) form is 5 pages long and contains:

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  • 14 check-boxes
  • 134 other fields

Country of origin: US
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Page 1 of 5
WIND ENERGY CONTRACTOR 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:
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:
General Contractor _________% Consultant _________%
Subcontractor _________% Developer _________%
Construction Manager ________%
GENERAL INFORMATION
OPERATIONS
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 5
6) In what states do you operate?
7) Are you licensed in all states in which you operate? Yes No
License Number(s):
8) Describe the nature of your operations:
9) Please complete the following chart:
Estimated Sales for
Next 12 Months
1
st
Prior Year
3
rd
Prior Year
4
th
Prior Year
Annual Gross Receipts
Employee Payroll
Cost of Subcontracted
Work
# of Employees
10) 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
11) Describe equipment used in your operations:
Cranes ft. Cherry Pickers ft.
Lifts ft. Other ft.
If Other is checked, please describe:
12) Do you have any offshore operations? Yes No
If yes, what percentage of your operations take place offshore? __________%
13) Do you manufacture or import any products? Yes No
If yes and a website is not indicated in the General Information section, please provide a product brochure for review.
Page 3 of 5
14) Are products sold under your label? Yes No
If yes, do you agree to grant sellers Additional Insured – Vendor status? Yes No
15) Do you distribute any products? Yes No
If yes, are you granted Additional Insured – Vendor status on the manufacturer’s policy? Yes No
16) Do you perform any installation or servicing? Yes No
17) If your operations include Wind Farms, complete the below table:
Location
Owner operated or LRO
Number of Acres
Number of Turbines
Annual Wattage Hours Generated
1.
2.
3.
4.
5.
18) For LRO and owner/operator wind farms, is land used for other purposes? Yes No
If yes, please describe:
19) For owners/operators of wind farms, to whom is generated-energy sold?
Utility Companies _________% Commercial (direct) _________%
Residential (direct) _________% Used for operations of insured _________%
20) During the past five years, has any insurer ever canceled or non-renewed similar Yes No
insurance to any applicant or has your insurance been canceled for nonpayment of
premium by any insurance or finance company. If Yes, please explain.
21) 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.
22) 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.
Page 4 of 5
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 5 of 5
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 Wind Energy Contractors Supplemental Application (Kinsale Insurance)

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Completed 16 July 2020

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