Fillable WAREHOUSE LEGAL LIABILITY SUPPLEMENTAL APPLICATION (Kinsale Insurance)

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WAREHOUSE LEGAL LIABILITY SUPPLEMENTAL APPLICATION (Kinsale Insurance)

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The WAREHOUSE LEGAL LIABILITY SUPPLEMENTAL APPLICATION (Kinsale Insurance) form is 6 pages long and contains:

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  • 63 check-boxes
  • 148 other fields

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Page 1 of 6
WAREHOUSE LEGAL LIABILITY – 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) Are you seeking blanket coverage? Yes No
a. Blanket Limit requested: $
7) Deductible requested:
8) Average insurable value at any one location you are operating: $
9) Minimum to maximum range of insurable value at any one location: $ to $
I. GENERAL INFORMATION
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 6
10) Please complete the following table for your receipts and payroll:
Revenue
Payroll
Projected Year
Last 12 Months
2nd Prior Year
11) How many employees do you have?
12) Are your employees bonded? Yes No
a. If yes, what bonding company?
13) Do you provide your own warehouse receipts or agreements? Yes No
a. If yes, please attach a copy.
b. If no, or if yes but your receipt is not always used, please attach details describing all other warehouse receipts,
storage contracts, or similar arrangements that you have with clients.
c. Do all agreements state that you are not liable for loss to the property unless caused by Yes No
your negligence?
d. Do all agreements state the maximum limit of liability which you accept for loss of or Yes No
damage to the client’s property? If yes, what is that maximum? $
c. What is the monthly storage charge? $
14) Please complete the following regarding commodities stored:
PROPERTY
PERCENTAGE
AVERAGE VALUE
Canned Goods
Other Food
Beer and Wine
Liquor and Spirits
Industrial Chemicals
Tobacco Products and Electronic Cigarettes
Cannabis and Hemp Products
Tires
Automobile Parts other than Tires
Rubber Goods other than Tires
Furniture
Appliances
Electronics
Clothing, Shoes, and Accessories
Paper Products
Other:
Other:
Other:
TOTAL:
100%
II. COMMODITIES
Page 3 of 6
15) Location Address:
City: State: Zip Code:
16) If you answered no to 6), what limit are you requesting for this location? $
17) Is this location owned or leased?
18) What is the square footage of the building?
19) What is the building construction material?
Frame Joisted Masonry Non-Combustible Masonry Non-Combustible
Fire-Resistive Other:
20) Please provide the following dates:
a. Year of building construction:
b. Year of last full roof replacement:
c. Year of last plumbing system update:
d. Year of last electrical/wiring update:
e. Year of last heating/HVAC system update:
21) What security and safety measures are in place at this location? Check all that apply:
Central Alarms - Fire Local Alarms - Fire Central Alarms - Burglar Local Alarms – Burglar
Sprinklers – Wet Sprinklers – Dry Sprinklers – In Rack Manual Fire Extinguishers
Security Guards Perimeter Fencing Gated/Barred Windows Security Cameras
Other: Other:
22) Do you have rack storage at this location? Yes No
23) Does this location have temperature and humidity control systems? Yes No
24) Are there any other occupants at this location? Yes No
a. If yes, who?
b. What are their operations?
25) Is this an open storage facility? Yes No
26) How frequently is physical inventory taken at this location?
Hourly Daily Weekly Monthly Other:
27) How often is inventory reconciled with the client?
Hourly Daily Weekly Monthly Other:
28) Does this location have temperature and humidity control systems? Yes No
29) Do you have any refrigerated storage at this location? Yes No
a. If yes, what type of refrigeration?
b. What temperature is maintained?
c. What is the refrigerated square footage?
d. Please describe your backup and auxiliary power systems:
III. LOCATION DETAILS (duplicate and complete this section for each individual location to be insured)
Page 4 of 6
e. Do you have a centrally monitored temperature alarm? Yes No
f. If yes, who is contracted in the event the central station receives an alert?
g. Do you have a local temperature alarm or visual alert? Yes No
h. Do you have 24/7 maintenance staff on duty? Yes No
i. What is the minimum number of staff on premise at any time?
j. How often is temperature checked and logged?
Continuously Hourly Daily Weekly Other:
1) Do you know of any incidents not currently reported to insurance that may result in a claim Yes No
against you? If yes, please attach an explanation.
2) During the past five years, has any insurer ever canceled or non-renewed similar insurance Yes No
to any applicant or has your insurance been canceled for nonpayment of premium by any
insurance or finance company? If yes, please attach an explanation.
3) Claim Details (duplicate this section 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:
Warehouse Legal Liability Refrigeration Breakdown Other Mechanical Breakdown
Pollution Legal Liability Commercial General Liability Other Commercial Property
Uninsured/Self Insured Other:
c. Please describe the circumstances leading up to the claim, the factual details of the incident, the inventory lost or
damaged, 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 require trial or arbitration to settle? Yes No
e. If this claim is open, do you anticipate it going to trial or arbitration? Yes No
+ If yes, when?
f. Were any of your procedures or rules changed after this incident? Yes No
g. Was the inventory a total loss/full insured value claimed? Yes No
h. Total claimed: $
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.
IV. CLAIMS HISTORY
Page 5 of 6
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.
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.
Page 6 of 6
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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WAREHOUSE LEGAL LIABILITY SUPPLEMENTAL APPLICATION (Kinsale Insurance)

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Completed 31 January 2021

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