CONTRACTORS EQUIPMENT RENTAL - Travelers



CONTRACTORS EQUIPMENT RENTALGENERAL LIABILITY APPLICATIONProposed First Named Insured & Other Named Insured(s): FORMTEXT ?????Mailing Address StreetCityCountyStateZIP Code FORMTEXT ?????Location Address StreetCityCountyStateZIP Code FORMTEXT ?????Telephone: FORMTEXT ?????Fax: FORMTEXT ?????Website: FORMTEXT ?????Contact for Inspection/Audit:Name: FORMTEXT ?????Phone No.: FORMTEXT ?????Business Type: FORMCHECKBOX Individual FORMCHECKBOX Partnership FORMCHECKBOX Corporation FORMCHECKBOX LLC FORMCHECKBOX Joint Venture FORMCHECKBOX Other (specify): FORMTEXT ?????Rental Agreements are required and should be written in accordance with the UCC and include a hold harmless provision protecting the retailer and transferring liability to the lessee; An assumption of risk by the lessee for damage to the lessor’s property.Proposed Effective Date: From: FORMTEXT ?????To: FORMTEXT ?????BUSINESS INFORMATION1.Number of Years in Business: FORMTEXT ?????Number of Years Experience: FORMTEXT ?????2.Radius of operations from the main location: FORMTEXT ????? Miles3.Estimated Annual:Payroll: $ FORMTEXT ?????Gross receipts: $ FORMTEXT ?????4.Total number of Employees: FORMTEXT ?????5.Do you have Workers’ Compensation coverage in force? FORMCHECKBOX Yes FORMCHECKBOX No6.Any work subcontracted? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, provide details: FORMTEXT ?????Cost of subcontractors: $ FORMTEXT ?????Are Certificates of Insurance required? FORMCHECKBOX Yes FORMCHECKBOX No7.List equipment being rented (if available, attach Equipment Schedule): FORMTEXT ?????8.Describe work being done: FORMTEXT ?????9.10.11.12.Any consumer rental (i.e. for personal homeowner use in lieu of experience/licensed contractors on all contractor/construction/industrial equipment)?Do you perform off-premises consultation, installation or repair and maintenance service on any equipment?Do you rent any of the following equipment: Derricks and power shovels; Log splitters; Demolition equipment; Drilling rigs?Any sales of used equipment?If yes, describe and include any warranties or guarantees. FORMTEXT ?????YesNo FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 13.If residential work is done, indicate percentage of work involving new versus existing construction:New: FORMTEXT ????? %Existing: FORMTEXT ????? %Any work involving residential tract developments? FORMCHECKBOX Yes FORMCHECKBOX NoIndicate percentage of work involving tract developments versus custom homes:Tract: FORMTEXT ????? %Custom: FORMTEXT ????? %14.Is all equipment rented with operator?If any equipment is rented without operator, a copy of the contract is required.a.Do any operators ever run the jobs?b.Do you bid on jobs?c.Do any jobs last longer than 30 days?YesNo FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 15.Do you have a contractor’s license?If yes, indicate type of license: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX 16.Do you make a thorough study of the subsurface, including identification of existing utility pipes and lines?Explain: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX 17.Is all self-propelled mobile equipment transported to job site on trailers?Explain: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX 18.Do you hold other persons’ property for service, storage or repair?Explain: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX 19.Any rental of the following:Barricades, Temporary Roadways, Access Mats or other road markingsSkidders or other logging equipmentTrailer hitchesLaddersScaffoldsAerial work platformsTrailersFarm equipmentBoilersPortable or hazardous waste tankExplain: FORMTEXT ?????YesNo FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 20.Any removal of underground fuel tanks?Any work on hillsides or slopes?Any mining?Any oil field work?Any earthen dam construction?Does the applicant use explosives?Excavation/grading of land on a contract basis?YesNo FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX PREVIOUS INSURER AND LOSS HISTORYMissouri Applicants: DO NOT answer this question.Has insurance of this type been cancelled, refused, or nonrenewed by any company during the past 3 years? FORMCHECKBOX No FORMCHECKBOX Yes - If Yes, give name of company, date, and reason: FORMTEXT ?????Indicate all claims or losses (regardless of fault and whether or not insured) or occurrences that may give rise to claims for the prior 3 years. FORMCHECKBOX See loss run attachedPolicyDatesCarrierPolicy NumberPremiumLossesPaidLossesReservedDescription FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????92773516129000SCHEDULE OF HAZARDSLOC#CLASSIFICATIONCLASSCODEPREMIUMBASISTERR.RATEPREMIUMPREM/OPSPRODUCTSPREM/OPSPRODUCTS FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????(s) Gross Sales(p) Payroll(a) Area(c) Total Cost(t) Other FORMTEXT ?????(s) per $1,000(p) per $1,000/pay(a) per 1,000 sq. ft.(c) per $1,000 cost(t) per unit FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????21.Do you have any other business ventures for which coverage is not requested? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, explain and advise where insured: FORMTEXT ?????For information about how Northland compensates its agents, brokers and program managers, please visit this website: you prefer, you can call the following toll-free number: 1-866-904-8348. Or you can write to us at Northland Insurance Companies, c/o Law Department, 385 Washington St., St. Paul, MN 55102.This application, including any material submitted in conjunction with the application or any renewal, does not amend the provisions or coverages of any insurance policy or bond issued by Northland.? It is not a representation that coverage does or does not exist for any particular claim or loss under any such policy or bond.? Coverage depends on the facts and circumstances involved in the claim or loss, all applicable policy or bond provisions, and any applicable law.? Availability of coverage referenced in this document can depend on underwriting qualifications and state regulations.FRAUD STATEMENTSARKANSAS, DISTRICT OF COLUMBIA, MARYLAND, NEW MEXICO, AND RHODE ISLAND: Any person who knowingly (or willfully in MD) presents a false or fraudulent claim for payment of a loss or benefit or knowingly (or willfully in MD) presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.COLORADO: 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 policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.FLORIDA: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.KENTUCKY, NEW JERSEY, NEW YORK, OHIO, AND PENNSYLVANIA: 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. (In New York, the civil penalty is not to exceed five thousand dollars ($5,000) and the stated value of the claim for each such violation.)LOUISIANA, MAINE, 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 may include imprisonment, fines, and denial of insurance benefits.IMPORTANT NOTICEDECLARATIONI DECLARE THAT THE STATEMENTS MADE IN THIS APPLICATION ARE COMPLETE AND TRUE.As part of our underwriting procedures, a routine inquiry may be made to obtain applicable information concerning character, general reputation, and credit history. Upon your written request, additional information as to the nature and scope of the report, if one is made, will be provided.SIGNATURESApplicant SignatureTitleDateProducer SignatureDateProducer Name and Address ................
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