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- Supplemental Application 2011 (Crum & Forster Insurance)

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FUEL MARKETER/JOBBER SUPPLEMENTAL APPLICATION
Agency:
Date Quote is Needed:
Account Name:
Target Premiums
Physical Address for Main Office:
Package $
& Auto:
Management’s Years of Experience:
Umbrella: $
FEIN:
Workers’ Comp $
Please submit completed Acord applications, this supplemental application and no less than four years
currently valued loss history thirty (30) days prior to the date you need your quote.
OPERATIONS
Fuel Distributor/Dealer
C-Stores and Retail Service Stations
Bulk Storage (other than LPG)
Aviation Fuel
LPG Bulk Storage
Marina Delivery/Direct Fueling of Watercraft
Propane Distributor/Dealer
Private Passenger Transportation
Home Heating Fuel
Common or Contract Carrier
Complete the following:
1.
Total No. of employees:
Tractor Trailer Drivers:
Bobtail Drivers:
Service Veh Drivers:
Plant Manager (s):
Mechanics:
Clerical Employees:
Custodial/Maintenance:
Other:
2.
Does Applicant haul any product he does not own?
Yes
No
What percentage?
% Type of
product?
Truckers Payroll (defined as payroll excluding drivers): $
3.
Does Applicant utilize common carriers to haul product on their behalf?
Yes
No
a. More than one Common Carrier firm utilized? If yes, how many?
Yes
No
b. Hired Carrier’s liability limits equal to Applicant’s liability limits?
Yes
No
c. Hired Carrier’s umbrella limits equal to Applicant’s limits?
Yes
No
d. Are COI’s obtained as verification that hired Carriers have appropriate limits?
Yes
No
4.
Does Applicant use independent owner/operators? If yes, ↓
Yes
No
a. Provide copy of contract used.
b. Does Applicant provide insurance for the vehicle(s)?
Yes
No
c. Are COI’s required from the owner/operator?
Yes
No
d. Does owner/operator haul for anyone other than the Applicant?
Yes
No
Type of Product?
5.
Does Applicant operate over a 300-mile radius? Yes No
Give one-way mileage:
Number of times per week:
6.
Does Applicant deliver any products to energy plants or nuclear processing plants?
Yes
No
If yes, explain.
7.
Does Applicant have a formal written safety plan? Yes No
8.
Does Applicant have a written emergency spill plan for drivers? Yes No
9.
Driver turnover is less than 10% 10% - 25% Over 25%
10.
Describe new driver training procedures:
11.
Does Applicant check the MVR prior to hiring a driver or drivers? Yes No
12.
What are minimum and maximum ages when hiring drivers?
/
13.
List any financial responsibility filings required:_____________________________________________________
14.
How are drivers paid?
Hourly
Mileage
Per Trip/Load
Other
Please explain:_______________________________
15.
DRIVER GUIDELINES
Attach a signed copy of Applicant’s hiring and firing guidelines on their company letterhead. Guidelines should be
specific and include minimum age, experience, and moving violations allowed within a specified period of time, such
as noted in the example below.
Minimum AMC Fairmont driver guidelines in addition to all DOT guidelines.
a. Minimum of 2 years verifiable experience driving like vehicles.
b. CDL where required with proper endorsements for a 2-yr period.
c. Preferred ages between 23 and 70.
d. No major violations including DUI, hit and run, manslaughter, use of vehicle in the commission of a felony, or
speeding in excess of 15 mph over the maximum-posted limit.
e. No reckless driving violation.
f. No more than 3 moving violations during previous 36 months or more than 2 in previous 24 months.
g. No more than 1 at-fault accident during previous 36 months or violation of operating a vehicle while license
suspended.
16.
Does Applicant own buildings and/or property leased to others? If yes, ↓ Yes No
a. Does Tenant carry premise liability with at least $1mm per occurrence GL limits and Fire
Legal limits equal to the replacement cost of the structure?
Yes
No
b. Does Tenant name the Applicant as Additional Insured on the Tenant’s policy and hold
the Applicant harmless?
Yes
No
c. Provide COI(s) with premise liability insurance at $1mm and Fire Legal at replacement cost of structure. List
Applicant on policy as Additional Insured.
17.
POLLUTION LIABILITY EXPOSURE
a. Does Applicant want Underground Storage Tank (UST) coverage from AMC Fairmont?
If yes, request UST Pollution application from your underwriter or assistant.
Yes
No
b. Does Applicant have UST coverage elsewhere? Yes No
c. Does Applicant elect to DECLINE UST coverage at this time? Yes No
Applicant must sign and date to decline.
Signature: Date:
Minimum Fairmont Specialty driver guidelines in addition to all DOT guidelines.
Fairmont Specialty
18.
BULK STORAGE (other than LPG) Number of Plants Operated:
Bulk Plant 1 Address:
a. Product Stored:
b. Number of Storage tanks AST’s:
UST’s:
c. Total gallon capacity:
Age of tanks:
Mo/Yr last certified
d. Are tanks fenced? Yes No Are tanks diked? Yes No
e. Bulk plant neighborhood: Residential Industrial Mercantile Outlying
f. Distance of tank(s) to nearest non-owned structure:
If less than 500’ provide ↓
Construction:
Occupancy:
Approximate value:
g. Have any facilities ever been cited, fined or in violation of EPA regulations? Yes No
Bulk Plant 2 Address:
a. Product Stored:
b. Number of storage tanks AST’s:
UST’s:
c. Total gallon capacity:
Age of tanks:
Mo/Yr last certified:
d. Are tanks fenced? Yes No Are tanks diked? Yes No
e. Bulk plant neighborhood: Residential Industrial Mercantile Outlying
f. Distance of tank(s) to nearest non-owned structure:
If less than 500’ provide ↓
Construction:
Occupancy:
Approximate value:
g. Have any facilities ever been cited, fined or in violation ̶of EPA regulations? Yes No
19.
LPG BULK STORAGE Number of Plants Operated:
Bulk Plant 1 Address:
a. Product Stored:
b. Number of storage tanks AST’s:
UST’s:
c. Total gallon capacity:
Age of tanks:
Mo/Yr last certified:
d. Are tanks fenced? Yes No
e. Bulk plant neighborhood: Residential Industrial Mercantile Outlying
f. Distance of tank(s) to nearest non-owned structure:
If less than 500’ provide ↓
Construction:
Occupancy:
Approximate value:
g. Have any facilities ever been cited, fined or in violation of EPA regulations? Yes No
Bulk Plant 2 Address:
a. Product Stored:
b. Number of storage tanks AST’s:
UST’s:
Yes No
20.
LPG CONTINUED
a. Does Applicant do HVAC work? (service or repair heating/air conditioning systems or other gas appliances) Yes No
If yes, provide payroll. $
b. Does Applicant sell: Space Heaters Water Heaters Gas Grills Other LPG appliances
Total receipts: $
c. Percentage of Automatic Fill customers:
% Will call Customers:
%
d. Does Applicant own any bottle filling operations not managed by owner or his employees? Yes No
If yes, explain:
e. Are scales used when filling bottles? Yes No
f. Does Applicant perform pressure checks on all out of gas customers? Yes No
g. Does Applicant perform pressure checks on all new customers? Yes No
h. In your estimation, what percentage of your propane customers has a documented leak test?
%
i. Describe new customer policy in detail:
j. Does Applicant deliver to out of gas customer when said customer is not home? Yes No
k. Describe out of gas policy in detail:
l. Are you a member of any industry association?
If yes explain___________________________________
m. Do all of your employees have CTEP, or similar training, in their respective job/work function?
n. Do you have any leased and/or seasonal employees? If yes, provide details:____________________________
o. Do you provide Workers’ Compensation for all of your employees?
p. Do you lease/loan construction heaters (salamanders) to others?
If yes, do you have written rental/lease agreement?
21.
HOME HEATING FUEL
a. Does Applicant perform tank installation, service, or removal? If yes, give details ↓ Yes No
Receipts from service work: $
Total receipts: $
b. Any sub-contracted operations? If yes, describe ↓ Yes No
c. Percentage of Automatic Fill customers:
% Will call customers:
%
d. Are customers notified of excess usage? If yes, describe procedure ↓ Yes No
e. How are requested gallons confirmed for Will Call customers?
f. Describe how drivers are trained and educated to locate and accurately identify fill pipes at customer locations?
g. Describe overflow prevention procedures:
h. Are spill kits carried on all delivery and service trucks? Yes No
22.
BULK OIL/USED OIL
a. Does Applicant do any oil blending or recycling? Yes No
b. Does Applicant have a permit to discharge wastewater? Yes No
c. Does Applicant do any delivery of asphalt? Yes No
23.
C-STORES AND RETAIL SERVICE STATIONS
a. Number of operated retail gasoline locations:
b. Locations with deep frying and/or grilling:
1. Ansul systems or other automated extinguishing system in place? Yes No
2. Provide a copy of contract between Applicant and cleaning/maintenance service company.
c. Any truck stops with lounge areas, showers, sleeping quarters, etc.? Yes No
d. Repairs performed at any locations? If yes, ↓ Yes No
1. Repairs to heavy trucks 20,000 pounds or heavier? Yes No
2. Are mechanics certified? If yes, by whom?
Yes No
e. How many owned/operated stations have wand type car washes:
24.
CRIME (C-STORES AND RETAIL SERVICE STATIONS)
a. Drop safes used at all locations? Yes No
b. Deposits made daily? Yes No
c. Deposits taken to central location? Yes No
d. Employees trained on how to react to a robbery? Yes No
e. Describe security system (central station, local, surveillance cameras, etc):
25.
LIQUOR LIABILITY (C-STORES AND RETAIL SERVICE STATIONS)
a. Total annual gross sales from beer, ale or wine ONLY: $
Give receipts per location on Acord GL application or AMC Fairmont
spreadsheet.
b. Total annual gross sales from hard liquor sales: $
c. Any consumption of alcohol on premises? Yes No
d. Owner/general manager’s years experience operating c-stores selling beer & wine:
e. Has the operation or applicant ever had a liquor liability claim? Yes No
f. Has the operation or applicant’s liquor license ever been suspended or revoked? Yes No
g. Describe the education, training or briefing given to employees regarding sale of alcoholic beverages:
h. Are guidelines posted for proper handling of suspected intoxicated customers and sale of
alcoholic beverages to intoxicated persons and minors?
Yes
No
i. Describe procedures to insure no sale to minors:
j. Is a report/record kept regarding all liquor incidents? Yes No
Give receipts per location on Acord GL application or Fairmont Specialty spreadsheet
b. Total annual gross sales from hard liquor sales:
26.
AVIATION FUEL
a. Estimated annual gallons of Jet A/B, JP 4/5 transported:
b. Estimated annual gallons of AvGas (80, 100, 100LL) transported:
c. Does transporter perform any direct servicing of aircraft? Yes No
d. Does transporter perform any fuel pre-mix or additive functions such as PRIST? Yes No
e. Does transporter have dedicated tank trailers or documented purging and cleaning
procedures?
Yes
No
f. Do supplier and retailer observe applicable fuel control standards such as promulgated in
NFPA407, 409, MIL-STD 15448c, ATA103, NATA and proprietary standards?
Yes
No
g. Is transfer of fuel conducted using standard procedure such as ↓
1. Review bill of lading and check seals Yes No
2. Check bonding/grounding of tank trailer Yes No
3. Collect sump samples for “clear and bright”, “white porcelain bucket” or “Aqua-glo”
water content tests
Yes
No
4. Inspect connections and hoses Yes No
5. Follow all other procedures required by applicable standards Yes No
27.
MARINA DELIVERY/DIRECT FUELING OF WATERCRAFT
a. Total annual gallons delivered to marinas:
b. Does Applicant do any direct fueling of watercraft? Yes No
1. What type of watercraft and how many times a month?
2. Total annual gallons direct fueled to watercraft:
c. In the event of an accidental spill, is there a barrier or dike between the tanks/pumps and
the water level that will prevent leakage?
Yes
No
d. Are vehicles that service marinas and/or fuel watercraft equipped with automatic shutoff
devices on the hoses? If yes, describe operation ↓
Yes
No
e. Does Applicant follow U.S. Coast Guard guidelines? Yes No
28.
PRIVATE PASSENGER TRANSPORTATION (PPT)
a. Are any PPT vehicles rated by ISO as high performance sports cars or valued over $80k? Yes No
Vehicle no.’s corresponding to Acord vehicle schedule:
b. Are all PPT’s registered in the business name? Yes No
c. Anyone under the age of 21 driving vehicles at any time? Yes No
d. Do children not living at home or working at the business drive any PPT? If yes, explain ↓
Yes
No
e. Are all PPT’s used in the day-to-day business operations? Yes No
f. Have ALL drivers been named in the Acord driver list including spouses and children? Yes No
List those not used in day-to-day business and explain use of vehicle:
All drivers must meet AMC Fairmont driver guidelines; otherwise, they will be excluded • Physician’s statements are required for drivers aged 70 and
older
Signature: Date:
All drivers must meet Fairmont Specialty driver guidelines; otherwise, they will be excluded • Physician's statements are required for drivers aged 70 and
APPLICANT’S STATEMENT
I have read the attached applications and I declare that to the best of my knowledge and belief all of the foregoing
statements are true, and that these statements are offered as an inducement to the Company to issue the policy for
which I am applying.
Named Insured Signature: Date:
Agency:
Producer’s Signature: Date:
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 CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION
CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDLENT INSURANCE ACT, WHICH IS A
CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES, INCLUDING BUT NOT LIMITED
TO FINES, DENIAL OF INSURANCE BENEFITS, CIVIL DAMAGES, CRIMINAL PROSECUTION, AND
CONFINEMENT IN A STATE PRISON.
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fuel marketers supp app 5.14
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Completed 13 July 2021

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