Fillable KINSALE Crane Supplemental Application

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KINSALE Crane Supplemental Application

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

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  • 36 check-boxes
  • 59 other fields

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Page 1 of 4
CRANE RENTAL SUPPLEMENTAL APPLICATION
COMPLETE IN ADDITION TO ACORD APPLICATIONS.
ATTACH ADDITIONAL SHEETS AS NECESSARY.
ANSWER ALL QUESTIONS. If not applicable, indicate N/A.
Please attach:
1) A list describing all equipment/cranes including their rated capacity and maximum boom length.
2) A copy of all rental agreements.
Applicant’s Name:
Street Address:
Mailing Address (if different):
City, St, Zip:
Web site:
Years in business under current ownership:
Years in business under current name:
SC&RA Member? Yes No
1. Please complete the following exposure information for the next 12 months:
Description of operations or services Direct labor payroll Gross revenue
Crane rental with operator
Bare crane rental
Millwright work which includes installation and repair
Steel Erection
Rigging that is done separately from other listed
operations
Heavy hauling
Sale of equipment
Other (describe)
APPLICANT’S INFORMATION
GENERAL INFORMATION
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 4
2. Please provide exposure information for prior years:
Current Year 1
st
2 Prior Year
nd
3 Prior Year
rd
4 Prior Year
th
Prior Year
Annual Gross Receipts
Employee Payroll
Cost of Subcontracted Work
# of Employees
3. Describe the types of equipment or objects typically lifted by your cranes.
4. Do you provide any specialized or unique services? Yes No
Describe:
5. What is your average “on hook” exposure? $
6. What is your maximum “on hook” value? $
7. Do you perform dual or tandem lifts? Yes No
8. Indicate which of the following you have or use:
Formal loss control or safety program? Yes No
Safety manager responsible for the safety program? Yes No
Regular safety meetings with employees? Yes No
Screening or reference process for new operators? Yes No
Crane operators Certified? Yes No
If so, what percentage? _______________%
A minimum age for operators? Yes No
What age? __________________
A scheduled maintenance program? Yes No
A written form for crane inspections? Yes No
An accident report form? Yes No
Are cranes certified? Yes No
If so, how often & by whom? _____________________________________________________
Is the maintenance done by the insured or by a 3
rd
9. On all Bare Rentals:
party? Yes No
1) Are Certificates of Insurance obtained from all Lessees? Yes No
2) Insured (Lessor) named as Additional Insured on Lessee’s policy? Yes No
Page 3 of 4
3) Lessee carries a minimum General Liability limit of $1,000,000? Yes No
4) Contract contains Hold Harmless/Indemnification Agreement in your favor? Yes No
10. What are the industries and/or customers predominantly serviced? (Example: Commercial
Construction, Industrial, Marine, Utility, Refineries, etc.)
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.
Page 4 of 4
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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KINSALE Crane Supplemental Application

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Completed 2 July 2020

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