Fillable KINSALE Mining Supplemental

Fill Online, Printable, Fillable, Blank KINSALE Mining Supplemental Form

Use Fill to complete blank online KINSALE INSURANCE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

KINSALE Mining Supplemental

On average this form takes 34 minutes to complete

The KINSALE Mining Supplemental form is 6 pages long and contains:

  • 1 signature
  • 85 check-boxes
  • 91 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Kinsale Insurance forms online.

BROWSE KINSALE INSURANCE 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
 
Page 1 of 6
MINING SUPPLEMENTAL APPLICATION
COMPLETE IN ADDITION TO ACORD APPLICATIONS.
ATTACH ADDITIONAL SHEETS AS NECESSARY.
ANSWER ALL QUESTIONS. If not applicable, indicate N/A.
1. Applicant:
2. Years in business: Years of experience:
3. Web site: www.
4. Have you operated or are you operating under a different business name now or at any time over Yes No
the past 10 years? Provide details:
5. State/area of operation:
6. Describe your operations:
Current Year 1
st
2nd Prior Year Prior Year 3
rd
4 Prior Year
th
Prior Year
Annual Gross Receipts
Employee Payroll
Cost of Subcontracted Work
# of employees
Inspection Contact Name:
Inspection Contact Phone Number:
1. MSHA Number: Mine Name:
2. Permit Number:
3. Mine Location/Directions to Mine (including County & State):
4. Acreage Associated with this Mine:
5. What is being mined?
6. Projected Clean Tons for this Mine:
7. Projected Raw Tons for this Mine:
APPLICANT’S INFORMATION
MINE INFORMATION
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 6
8. Type of Mine:
Surface
If Surface, is this mine: Open Pit
Highwall Miner
Mountaintop Removal
Coutour
Auger
Other, Please Provide Details: ____________________________
Underground
If Underground, is this mine:
Longwall
Shortwall
Slope
Drift
Shaft
Advancing
Retreat
Continuous
Conventional (cut and Shoot)
Other, Please Provide Details: ______________________________
9. Operations at this mine. Do you:
Own or Control Mining Permit and Operates Mine
Own or Control Mining Permit, but Mine is Operated by Contract Miner
Contract Miner Operating Mine under Contract with Permit Owner
Provide Leased Employees or Contract Labor to Mine Operators
Landowner – Owns the Land (no permits) and Leases the Land to Others
Operate Prep Plant or Other Processing Facility
Operate a Tipple, Truck, Rail or Barge Load-Out Facility
Own an Inactive Mine – Permanently Closed, Waiting for Bond Release, or Temporarily Shut down.
Other:
10. Please describe the security measures used at this mine:
11. Is there any sort of barrier used at this mine (gate, fence, cable, chain, etc)? Yes No
If yes, please specify the type used.
12. Do you lease or loan equipment to others? Yes No
If yes, please provide details:
13. Do you own or control any dwellings or stores? Yes No
14. Do you own or control any recreational facilities? Yes No
15. Do you provide transportation for employees or subcontractors? Yes No
16. Are any impoundments with a dam associated with this mine? Yes No
Page 3 of 6
17. Are there any waste treatment ponds associated with this mine? Yes No
18. Are there any gob, waste or tailings piles associated with this mine? Yes No
19. Is any work associated with this mine performed by leased workers or contract labor? Yes No
If yes, please provide details on the type of work performed by the leased workers or contract labor:
1. Is any blasting performed at this mine? Yes No
If yes, is the blaster an employee or a contractor? Please provide the name of the employee or contractor.
If the blaster is a contractor, please attach a complete copy of your contract with the blaster.
If yes, please describe the training and experience of the blaster:
2. What is the distance from the blast site to the closest third party structure?
3. Are pre-blast surveys performed? Yes No
If yes, who performs them?
4. Are seismographic recordings made of each blast? Yes No
If yes, who performs them?
1. Has pollution or any similar coverage ever been canceled or refused to you? Yes No
If yes, please provide details.
2. Have you in the last five years ever been cited or prosecuted for violation of any standard or law Yes No
relating to the release of a substance into the environment?
If yes, please provide details.
3. Have you ever been sued or requested to pay damages or to investigate environmental contamination Yes No
or perform any remediation with respect to any actual or alleged pollution incident?
If yes, please provide details.
BLASTING INFORMATION
POLLUTION INFORMATION
Page 4 of 6
4. Have there ever been any emissions, discharges, or escapes of pollutants or other substances Yes No
above permissible levels at any sites for which this application is being made?
If yes, please provide details.
5. Do you have an environmental management department or any employees vested with the Yes No
responsibility for environmental control?
6. Are you aware of any fact or circumstance that might lead to a claim under the policy if it were to Yes No
be issued?
If yes, please provide details.
7. Are you currently in compliance with all federal, state and local environmental laws and permits? Yes No
If no, please provide details.
8. Please describe all environmental and pollution losses that occurred during the last five years whether they were
covered by insurance or not.
1. What percent of work do you subcontract to others? %
2. Do you usually use the same subcontractors? Yes No
3. Are subcontractors always insured? Yes No
4. What general liability limits do you require your subs to carry?
5. Are you named as an additional insured on all subcontractors’ policies?
6. Do you have a written contract with your subcontractors? If yes provide a copy. Yes No
7. Do you obtain certificates of insurance from all subcontractors? Yes No
8. How long do you retain those certificates?
9. Do you have a formal safety program? Yes No
10. Do you provide a watchman or security at job sites? Yes No
11. During the past five years, has any insurer ever canceled or non—renewed similar insurance to any Yes No
applicant or has your insurance been canceled for non—payment of premium by any insurance
or finance company?
OTHER
Page 5 of 6
If yes, please explain:
12. Has any lawsuit ever been filed, or any claim otherwise been made against your company or any Yes No
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 explain including the name(s) of the person, company or entity and the name(s) and locations(s)
of the projects where such operations were performed. (Attach separate sheet if necessary.)
13. Is your company aware of any occurrences, facts, circumstances, incidents, situations, damages or Yes No
accidents (including but not limited to: allegations of faulty or defective workmanship, product failure,
construction dispute, property damage or construction worker 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 explain including the names(s) and location(s) of the projects where such operations were
Performed. (Attach a separate sheet if necessary.)
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.
Page 6 of 6
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:
(Must be signed by a Principal, Partner, or Officer of the Firm)
FEIN #:
Applicant’s Signature: Date:
Agent/Broker Name:
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

KINSALE Mining Supplemental

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 2 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document