Fillable Wind & Solar Energy Liability Application (RT Specialty)

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Wind & Solar Energy Liability Application (RT Specialty)

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  • 24 check-boxes
  • 465 other fields

Country of origin: US
File type: PDF

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Scottsdale Insurance Company
Home Office: One Nationwide Plaza
Columbus, Ohio 43215
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
Scottsdale Indemnity Company
Home Office: One Nationwide Plaza
Columbus, Ohio 43215
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
Scottsdale Surplus Lines Insurance Company
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
1-800-423-7675 • Fax (480) 483-6752
www.scottsdaleins.com
Wind & Solar Energy Liability Application
Applicant’s Name:
Mailing Address:
Web site Address:
Agency Name:
Agent:
Address:
E-mail:
Phone:
PROPOSED EFFECTIVE DATE: From To 12:01 A.M., Standard Time at the address of the Applicant
ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE”
Applicant is: Individual Corporation Partnership Joint Venture
Limited Liability Company Other (Specify):
Description Of Operations (indicate all that apply):
Solar Energy Contractors Wind Turbine Contractors
Solar Energy Equipment Dealers or Distributors only Wind Turbine Equipment Dealers or Distributors only
Solar Energy Farms Wind Farms-on-shore
Solar Energy Systems-Existence hazard only (LRO) Wind Turbines-Existence hazard only (LRO)
Other (Specify):
Limits Of Liability & Deductible Requested:
General Aggregate
(other than Products/Completed Operations)
$
Products & Completed Operations Aggregate
$
Personal & Advertising Injury (any one person or organization)
$
Each Occurrence
$
Damage To Premises Rented To You (any one premise)
$
Medical Expense (any one person)
$
Other Coverages, Restrictions, and/or Endorsements:
$
Deductible
$
GLS-APP-78s (9-11) Page 1 of 8
Submit Application
1. Location Of Operations:
Loc. No. Street Address and City
State
1. Same as mailing address
2.
3.
4.
2. Contact person: Title:
Phone number:
3. Length of time in business under applicant’s name shown above: years or new venture.
Years of experience:
Is applicant licensed? .................................................................................................................................. Yes No
Has applicant operated or been licensed under any other name(s) during the past ten (10) years? ......... Yes No
If yes, provide prior name and describe type of operations:
Name Description of Operations
4. Schedule Of Hazards:
Loc.
No.
Classification Description
Class.
Code
Exposure
Premium Basis
(s) Gross Sales
(p) Payroll
(a) Area
(c) Total Cost
(t) Other
5. List all major projects completed within the last five years, including work in progress and planned projects.
Project Name Date Project Description Location Revenues
$
$
$
$
$
GLS-APP-78s (9-11) Page 2 of 8
6. Total number of employees:
Number certified in: solar energy installation: wind energy installation:
Type of certificates:
North American Board of Certified Energy Practitioners (NABCEP) ........................................................... Yes No
If no, provide details:
7. Account history for prior five years and projected current year:
Year Payroll Total Revenue
Subcontracted Cost
(a)
Cost of Labor, Fees
and Commissions
(b)
Cost of Materials
& Equipment Rental
(c) (a+b=c)
Total
Subcontracted Cost
Current $
$
$
$
$
1st Prior $
$
$
$
$
2nd Prior $
$
$
$
$
3rd Prior $
$
$
$
$
4th Prior $
$
$
$
$
5th Prior $
$
$
$
$
8. Does applicant have a formal safety program in operation? ................................................................ Yes No
If yes, provide details and/or attach a copy:
9. Does applicant have Workers’ Compensation coverage in force? ...................................................... Yes No
10. Any employees working under U.S. Longshoremen's and Harborworkers' Act or Jones Maritime
Act? .............................................................................................................................................................
Yes No
If yes, what percent of payroll? % Give city and state:
11. Does applicant use subcontractors? ...................................................................................................... Yes No
If yes:
a. Are all subcontractors required to carry General Liability and Workers Compensation Insurance? .... Yes No
b. Are certificates of insurance obtained from all subcontractors? ........................................................... Yes No
If yes, indicate minimum limit of liability required: $
c. Does applicant require all subcontractors to include the applicant as an additional interest on all
subcontractors’ policies? .......................................................................................................................
Yes No
d. Do written contracts contain hold-harmless agreements in favor of the applicant? ............................. Yes No
If no, explain when not required:
12. Is any operation insured elsewhere by an owner-controlled insurance program (OCIP), also
referred to as wrap insurance? ................................................................................................................
Yes No
If yes, provide details:
13. Describe equipment used in operations:
Cranes/Cherry Pickers/Lifts—Maximum height:
14. Does applicant or applicant’s subcontractors use explosives? .......................................................... Yes No
15. Is applicant involved in any hydro energy operations? ........................................................................ Yes No
16. Is applicant involved in any offshore operations? ................................................................................. Yes No
GLS-APP-78s (9-11) Page 3 of 8
17. Is applicant involved in any biodiesel operations? .................................................................................. Yes No
18. Is applicant involved in any biomass operations? ................................................................................... Yes No
19. Is applicant involved in any geothermal energy operations? ................................................................. Yes No
20. Does applicant manufacture any products? ............................................................................................. Yes No
21. Any products sold under applicant’s label? ............................................................................................. Yes No
22. Does applicant verify manufacturers have products liability coverage? .............................................. Yes No
23. Is applicant named as additional insured by the manufacturer(s)? ....................................................... Yes No
24. If applicant is a dealer or distributor, does applicant also install and service products? ................... Yes No
25. Does applicant import directly from foreign countries? ......................................................................... Yes No
26. Does applicant sell any used items? ......................................................................................................... Yes No
If yes, what percent of sales does this represent? ........................................................................................ %
Any refurbishing or repair done prior to resale? ............................................................................................ Yes No
27. Does applicant hold a patent or ever involved in the design of any product? ..................................... Yes No
If yes, explain:
28. Does applicant own or maintain any electric transmission distribution lines or substations? .......... Yes No
If yes, describe line length (miles) and number of substations:
29. New York risks only: Any operations over three stories in height? ...................................................... Yes No
30. Any other insurance with this company or being submitted? ................................................................ Yes No
If yes, list name(s) and/or policy number(s):
31. During the past three years, has any company ever canceled, declined, or refused similar
insurance to the applicant? (Not Applicable in Missouri) ...........................................................................
Yes No
If yes, advise:
32. Does applicant have other business ventures for which coverage is not requested? ........................ Yes No
If yes, explain and advise where insured:
33. Additional Insured Information:
Name Address Interest
34. Prior Carrier Information:
Year:
Year:
Year:
Year:
Year:
Carrier
Policy Number
Coverage
Total Premium $
$
$
$
$
GLS-APP-78s (9-11) Page 4 of 8
35. Loss History—Five-Year Period:
Indicate all claims or losses (regardless of fault and whether or not insured) or occurrences that may give
rise to claims for the prior five years. .............................................................
Check if no losses last five years.
Date of
Loss
Description of Loss Amount Paid
Amount
Reserved
Claim Status
(Open or Closed)
$
$
$
$
$
$
$
$
$
$
36. Attach the following if applicable:
a. Details of all losses in excess of ten thousand dollars ($10,000): .......................................................... Yes No
b. Agreement with Utility Company? ........................................................................................................... Yes No
c. Installation Warranty? .............................................................................................................................. Yes No
d. Product Warranty? .................................................................................................................................. Yes No
37. Solar Energy or Wind Farms (Complete if applicable to applicant’s operations):
a.
Energy Farms:
Loc.
No.
Solar Energy Farms Wind Farms
Indicate
Owner
Operated
or
Lessors
Risk Only
No. of
Acres
Annual
Wattage
Hours
Generated
Indicate
Owner
Operated
or
Lessors
Risk only
No. of
Acres
No. of
Turbines
Maximum
Height of
Turbines
Annual
Wattage
Hours
Generated
1
2
3
4
b. Site Security:
On-site security: ...................................................................................................................................... Yes No
If yes, describe:
Is site fenced? ......................................................................................................................................... Yes No
If yes, height of fence: Type:
Is site posted for No Trespassing? .......................................................................................................... Yes No
c. How far are the wind turbines from neighbors building/home?
d. Does applicant have any wind turbines without a lightning-specific warranty?............................ Yes No
If yes, explain:
e. Proximity to nearest airfield: miles
GLS-APP-78s (9-11) Page 5 of 8
f. Do any rail lines, pipelines, or public roads pass through the property? ....................................... Yes No
If yes, describe:
g. Is land used for other purposes? ........................................................................................................ Yes No
If yes, describe:
h. Energy Generated is (% of each—Complete if owner operated):
Sold to Utility Companies: % Name of Utility Company:
Sold directly to Commercial/Industrial Companies: ................................................................................. %
Sold directly to Residential Consumers: .................................................................................................. %
Used only for operations of the insured: .................................................................................................. %
Other (describe): %
38. Solar Energy (Complete if applicable to applicant’s operations):
a. Types of Solar Systems installed, serviced or repaired (% of each):
Solar Photovoltaic Systems Commercial % Residential %
Solar Thermal Systems Commercial % Residential %
Other: Describe: Commercial % Residential %
b. Does applicant use only components approved by the Solar Rating and Certification
Corporation (SRCC)? ............................................................................................................................
Yes No
If no, provide details:
c
. What types of services and repairs does applicant perform?
d. Are the following types of services provided?
(1) Qualify the system to achieve customer electrical load and energy use. ......................................... Yes No
(2) Determine the location and impact of buildings, trees, local terrain and other obstacles at the
client’s site and suggest solutions to overcome their interference. ..................................................
Yes No
(3) Estimate output performance for the client, including the impact on their utility bill for on-grid
systems or energy contribution to an off-grid battery charging system. ...........................................
Yes No
39. Wind Energy (Complete if applicable to applicant’s operations):
a
. What types of installation, services and repairs does applicant perform?
b. Does applicant construct or maintain wind turbines that produce more than one hun-
dred (100) kilowatts (kw.) of power? .................................................................................................
Yes No
If yes, what percent of sales does this represent? ................................................................................. %
c. Does applicant service or repair wind turbine/tower structures in excess of two hun-
dred (200) feet (height from the ground to the top of the blades)? ...............................................
Yes No
If yes, what percent of sales does this represent? ................................................................................ %
GLS-APP-78s (9-11) Page 6 of 8
d. Types of wind turbine systems applicant sells and/or installs:
Turbine
Turbine Type
No. 1
Turbine Type
No. 2
Turbine Type
No. 3
Turbine Type
No. 4
Model number
kw. capacity
% of turbines installed
%
%
%
%
Blade length from tip of
the blade to center of
propeller
ft. ft. ft. ft.
Tower % of Total Installed Maximum Height
Lattice type
%
ft.
Tube type
%
ft.
If other, describe:
%
ft.
Height of the systems:
Combined height of tower and
turbine blades from ground level to
highest point of turbine blades
Minimum Height Maximum Height Average Height
ft. ft. ft.
e. Turbines sold or installed are manufactured by:
Type No. 1: Mfgr. Web site:
Type No. 2: Mfgr. Web site:
Type No. 3: Mfgr. Web site:
Type No. 4: Mfgr. Web site:
f. Are geotechnical reports completed on all installation projects? ................................................. Yes No
If no, advise reason not needed.
g. Describe operations involving testing and certification (commissioning):
h. Are the following types of services provided?
(1) Qualify the system to achieve customer electrical load and energy use? ..................................... Yes No
(2) Determine the location and impact of buildings, trees, local terrain and other obstacles at the
client’s site and suggest solutions to overcome their interference? ...............................................
Yes No
(3) Determine the minimum acceptable tower height for the client’s site? .......................................... Yes No
(4) Estimate turbine output performance for the client, including the impact on their utility bill for
on-grid systems or energy contribution to an off-grid battery charging system? ...........................
Yes No
This application does not bind the applicant nor the Company to complete the insurance, but it is agreed that the infor-
mation contained herein shall be the basis of the contract should a policy be issued.
FRAUD WARNING: 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 fraudulent insurance act, which is a crime and
subjects such person to criminal and civil penalties. (Not applicable to Nebraska, Oregon or Vermont).
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 policy holder or claimant with regard to a settlement or award pay-
able from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory
Agencies.
GLS-APP-78s (9-11) Page 7 of 8
WARNING TO DISTRICT OF COLUMBIA APPLICANTS: 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 in-
surer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a
felony in the third degree.
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 sub-
ject 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 a denial of
insurance benefits.
NOTICE TO MARYLAND APPLICANTS: Any person who knowingly and willfully presents a false or fraudulent claim for
payment of a loss or benefit or who knowingly and willfully 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 MINNESOTA APPLICANTS: A person who files a claim with intent to defraud or helps commit a fraud
against an insurer is guilty of a crime.
NOTICE TO OHIO APPLICANTS: Any person who knowingly and with intent to defraud any insurance company 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
subjects such person to criminal and civil penalties.
NOTICE TO OKLAHOMA APPLICANTS: Any person who knowingly, and with intent to injure, defraud or deceive any
insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading infor-
mation is guilty of a felony.
NOTICE TO RHODE ISLAND 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.
FRAUD WARNING (APPLICABLE IN TENNESSEE, VIRGINIA AND WASHINGTON):
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.
FRAUD WARNING APPLICABLE IN THE STATE OF NEW YORK: 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
fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars
and the stated value of the claim for each such violation.
APPLICANT’S NAME AND TITLE:
APPLICANT’S SIGNATURE: DATE:
(Must be signed by an active owner, partner or executive officer)
PRODUCER’S SIGNATURE: DATE:
NAME AND PHONE NUMBER OF INDIVIDUAL TO CONTACT FOR INSPECTION/AUDIT:
IMPORTANT NOTICE
As part of our underwriting procedure, a routine inquiry may be made to obtain applicable information concerning
character, general reputation, personal characteristics and mode of living. Upon written request, additional
information as to the nature and scope of the report, if one is made, will be provided.
GLS-APP-78s (9-11) Page 8 of 8
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Wind & Solar Energy Liability Application (RT Specialty)

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Completed 13 December 2020

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