Fillable TRIP TRANSIT SUPPLEMENTAL APPLICATION (Kinsale Insurance)

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TRIP TRANSIT SUPPLEMENTAL APPLICATION (Kinsale Insurance)

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  • 27 check-boxes
  • 98 other fields

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Page 1 of 5
TRIP TRANSIT – SUPPLEMENTAL APPLICATION
ATTACH ADDITIONAL SHEETS AS NECESSARY.
ANSWER ALL QUESTIONS. If not applicable, indicate N/A.
1)
Named Insured:
Brokerage/Broker:
New Venture?
Yes No
Renewal?
Yes No
Policy Number:
Current Effective Date:
Current Expiry Date:
Requested Effective Date:
Requested Expiry Date:
Website:
2) Current Carrier Information:
Expiry Date:
Yes No
Please attach copies of the following:
a) Currently valued five-year loss runs, including complete claim details for all losses
b) Applicant’s description of operations, brochure, or marketing materials if a website is not available
3) Mailing Address:
City: State: Zip Code:
4) Are you a(n): Corporation Individual Partnership Municipality For Profit
Joint Venture Other:
5) How long have you been in operation under this business name or any others (please provide any prior entities or
additional entities/DBAs to be covered)?
6) Please complete the following table for your receipts:
Sales
Projected Year
Last 12 Months
2nd Prior Year
I. GENERAL INFORMATION
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 5
7) What property is being shipped?
8) What is the distance the shipment will travel? miles
9) What is the point of departure?
10) What is the destination?
11) How long will it take the property to reach the destination?
12) What methods of conveyance are used? Check all that appl and the requested limits of insurance for each:
Railroad $ Your Vehicle $
Contract Carriers $ Common Carriers $
Air Carriers $ Messenger/Couriers $
Other: $
Other: $
13) Do you plan routes in advance of shipment departure? Yes No
a. Are alternate routes planned in the event of an unavoidable or emergency deviation? Yes No
b. Are there any specific protocols that must be followed in the event of a route Yes No
deviation?
c. If yes, please describe:
14) Do you utilize specialized containers to reduce handling, pilferage and theft losses? Yes No
a. If yes, please describe container specifications. Attach diagrams if necessary:
b. If no, how are handling, pilferage and theft losses mitigated?
15) Are loaded vehicles parked unattended at night? Yes No
16) Are the employees that pack, load and unload the shipments trained in the proper handling Yes No
of the shipments?
a. How frequently are employees re-trained?
b. How do you ensure handling protocols are observed?
17) If you are utilizing carriers for shipment, please complete the following:
a. Is there any release of values/liability given to the carriers handling your property? Yes No
b. If yes, please attach details.
c. Does the company shipping the goods provide insurance coverage? Yes No
d. Do you utilize the same company or companies for all shipments? Yes No
e. If yes, what company?
f. What minimum qualifications do you require for carriers (eg years of experience with the type of property being
hauled, years in operations, etc.)?
II. SHIPMENT PROTECTION
Page 3 of 5
18) Do you know of any incidents not currently reported to insurance that may result in the filing Yes No
of a claim? If yes, please attach an explanation.
19) Claim Details (duplicate this page for all claims)
a. What was the date of the incident?
b. What line(s) of your coverage(s) was this claim reported on? Check all that apply:
Carrier’s Motor Truck Cargo Carrier’s Contingent Cargo Trip Transit Policy
Ocean Marine Policy Commercial General Liability Other:
c. Please describe the circumstances leading up to the claim, the factual details of the incident, the property lost,
and steps taken following the incident to mitigate loss and evaluate the claim. Please note “attached” and
include an additional sheet if the details do not fit below:
d. If this claim is closed, did it settle without trial? Yes No
e. If this claim is open, is a hearing, trial or arbitration date set? Yes No
+ If yes, when?
f. Do you still contract with the carrier involved in this loss? Yes No
g. Was all cargo lost/the full value of the bill of lading or shipping receipt claimed? Yes No
+ If no, what percentage was lost? %
h. Total damages claimed: $
i. Claim total: $
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.
III. CLAIMS HISTORY
Page 4 of 5
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:
FEIN #:
Applicant’s Signature: Date:
Agent/Broker Name:
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TRIP TRANSIT SUPPLEMENTAL APPLICATION (Kinsale Insurance)

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Completed 31 January 2021

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