Fillable KINSALE Pipeline Operators Supplemental

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KINSALE Pipeline Operators Supplemental

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Page 1 of 5
PIPELINE OPERATOR SUPPLEMENTAL APPLICATION
COMPLETE IN ADDITION TO ACORD
APPLICATIONS.
ATTACH ADDITIONAL SHEETS AS NECESSARY.
ANSWER
ALL
QUESTIONS. If not applicable, indicate
N/A.
APPLICANT’S INFORMATION
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 Yes No
over
the
past
10
years?
Provide
details:
5.
State/area
of
operation:
Current Year
1
st
Prior Year
2nd Prior Year
3
rd
Prior Year
4
th
Prior Year
Annual Gross Receipts
Employee Payroll
Cost of Subcontracted Work
# of employees
1. Are you an operator or non-operator of the pipeline? Yes No
2. What product is transported via the pipeline?
If
gas,
is
it
odorized?
Yes No
If
Yes,
by
whom:
3.
When
was
the
pipeline
built?
4.
How long
is
the
pipeline?
5.
What
is
the
pipeline’s
diameter?
APPLICANT’S INFORMATION
GENERAL INFORMATION
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 5
6.
What
is
the
construction
type
of
the
pipeline
(Steel,
plastic,
etc)?
7.
Is
the
pipeline
system
mapped?
8. Is the pipeline above or below ground?
If
below,
to
what
depth
is
it
buried
and
how
much
of
the
pipeline
is
buried?
9.
What
is
the
maximum
PSI
of
the
pipeline?
What
is
the
operational
PSI?
10.
What
are
the
surrounding
3
rd
party
exposures
of
the
pipeline
(populated
areas,
etc)?
11. Is the pipeline crossing any rivers, creeks or roads? Yes No
If
Y
es,
please
explain:
12.
Is
the
pipeline
cathodically
protected?
Yes No
How
much
of
the
line
is
protected?
13.
Is
the
pipeline
coated?
Yes No
How
much
of
the
pipeline
is
coated?
14. What is the annual leakage rate of the pipeline? %
15.
How
often
is
the
pipeline
inspected
and/or
walked?
16.
Please
detail
your
present
inspection
procedures:
17. Does the insured employ the use of drones? Yes No
a. If yes, how many drones are used?
b. What are drones being used for (inspections, leak detection, etc)?
c. Who is controlling/piloting the drone(s)?
d. Are the drones registered with the FAA? Yes No
18.
What
are
your
leak
detection
methods (other than drones)?
19.
How
are
you
addressing
corrosion
and
pipe
degradation
of
the
pipeline?
20.
Please
detail
your
present
replacement/maintenance
program:
21. Do you use in-line inspections? Yes No
If yes, when were they last done?
How often are they conducted?
Page 3 of 5
22.
Please
detail
your
emergency
response
procedures:
23. Do you have an agreement with an emergency response provider in place?
24. What permits, filing, licenses, etc do you make with governmental bodies (DOT, RR Commission, etc)?
25. What percent of work do you subcontract to others? %
26. Do you usually use the same subcontractors? Yes No
27. Are subcontractors always insured?
28.
What
general
liability
limits
do
you
require
your
subs
to
carry?
29.
Are
you
named
as
an
additional
insured
on
all
subcontractors’
policies?
30. Do you have a written contract with your subcontractors? Yes No
If Yes, please provide a copy.
31. Do you obtain certificates of insurance from all subcontractors? Yes No
32.
How
long
do
you
retain
those
certificates?
Describe your last 5 projects
Dollar Value
1.
2.
3.
4.
5.
Describe your 5 largest projects
Dollar Value
1.
2.
3.
4.
5.
33. During the past five years, has any insurer ever canceled or non-renewed similar insurance to Yes No
any applicant or has your insurance been canceled for non—payment of premium by any insurance
or finance company?
If
yes,
please
explain:
Page 4 of 5
34. Has any lawsuit every been filed, or any claim otherwise been made against your company or
Yes No
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 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.)
35. 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 o
r 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 5 of 5
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:
(Must be signed by a Principal, Partner, or Officer of the Firm)
Title:
FEIN #:
Applicant’s Signature: Date:
Agent/Broker Name:
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KINSALE Pipeline Operators Supplemental

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Completed 2 July 2020

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