Fillable KINSALE Blasting Supplemental Application

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KINSALE Blasting Supplemental Application

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The KINSALE Blasting Supplemental Application form is 4 pages long and contains:

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Page 1 of 4
BLASTING CONTRACTORS
SUPPLEMENTAL APPLICATION
COMPLETE IN ADDITION TO ACORD AND CONTRACTORS SUPPLEMENTAL APPLICATIONS
ATTACH ADDITIONAL SHEETS AS NECESSARY.
.
ANSWER ALL QUESTIONS. If not applicable, indicate N/A.
1. Applicant:
2. Street Address:
3. Mailing Address (if different):
City, State, Zip:
4. Business Location Address:
5. Has Applicant had previous insurance for this enterprise? Yes No
If Yes, provide the following information:
INSURANCE COMPANY POLICY PERIOD LIMITS OF
INSURANCE
PREMIUM OCCURRENCE OR
CLAIMS MADE
6. Is Applicant engaged in, owned by, associated with or involved in any other enterprise? Yes No
If Yes, provide full details.
7. Provide details of licenses and certifications held:
8. During the past 3 years, have any claims been presented to your current or prior insurance carrier? Yes No
If Yes, provide details including description of claim, amounts paid and reserves.
9. Is the Applicant, or any other person for whom insurance is being requested, aware of any Yes No
circumstance which may result in a claim?
If Yes, give full details.
GENERAL INFORMATION
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 4
10. Has Applicant or any other person for whom coverage is being requested, had any liability Yes No
application denied, policy cancelled or policy not renewed in the past 3 years?
If Yes, give full details.
11. Has the Applicant or any other person for whom coverage is being requested, ever been fined or Yes No
Cited for performing unsafe work?
If Yes, give full details.
12. How many years of experience have you had in the blasting business? Years
13. Do you have a standard contract that you use for all projects and work? Yes No
(If Yes, please furnish a copy.)
14. Is a pre-blast survey conducted at the jobsite and any areas surrounding the site to ascertain Yes No
proximity of any structures, including identification of existing utility pipes and lines, which
could be damaged?
15. Does the pre-blast survey include pictures of pre-existing property damage to surrounding Yes No
structures?
16. Are stabilization devices used such as support braces or retaining walls to protect structures Yes No
whose integrity might be compromised by blast impact?
17. Does insured have sufficient barricades, fences, flags or signs such as “caution-blasting in Yes No
progress” or “blasting zone – 1,000 feet” to keep non-employees at a safe distance from
jobsites and equipment?
18. Does insured protect third parties in area(s) where explosives will be detonated, using protective Yes No
Materials such as thick, finely woven steel wire mats?
19. Are electric-blasting circuits of sufficient current carrying capacity and not grounded? Yes No
20. Are connecting wires insulated and of single-wire type? Yes No
21. If electric detonation devices are used, are extraneous power sources which may cross the Yes No
wire’s path or interfere with electric-blasting circuits shut off or disconnected?
22. If blasting is done by using a fuse, is sufficient time allowed for the blaster to reach a point Yes No
of safety well in advance of anticipated detonation time?
23. If mobile radio transmitters are used to detonate charges, are warnings such as “turn-off 2-way Yes No
radios” posted around a 1,000 foot perimeter of the blasting site?
24. Are only authorized and experienced personnel permitted to handle explosives? Yes No
25. Are explosives transported to the site as close to blasting date as possible? Yes No
If No, how is exposure to possible above ground detonation limited?
Page 3 of 4
26. Are explosives secured in a fire-resistant magazine when not in use? Yes No
If No, explain other type of containers used.
27. Are ignition sources, such as smoking and open flames prohibited within 50 feet of explosive Yes No
storage or use?
If No, please explain.
28. Do you subcontract any blasting? Yes No
If Yes, describe specific type of work.
29. Are certificates of insurance obtained from subcontractors confirming blasting/explosion/ Yes No
explosive coverage?
If Yes, list limits of liability required on certificates.
30. Do you comply with OSHA blasting standards and general provisions for use of explosives? Yes No
31. Are records maintained on unused explosives for return to appropriate suppliers pursuant to Yes No
OSHA standards for storage of explosives and blasting agents?
Describe your 2 largest jobs.
SIGNING THIS QUESTIONNAIRE DOES NOT BIND THE APPLICANT OR THE INSURER TO COMPLETE THE INSURANCE.
WARRANTY: It is warranted to Kinsale Insurance Company that the information contained herein is true and that it shall be
the basis of the policy of insurance and deemed incorporated therein should the Company evidence its acceptance of the
application by issuance of a policy. I/We hereby authorize the release of claim information from any prior insurer to Kinsale
Insurance Company.
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.
SUBCONTRACTORS
Page 4 of 4
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.
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:
Applicant’s Signature: Date:
Agent/Broker Name:
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KINSALE Blasting Supplemental Application

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Completed 2 July 2020

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