Contractor's Equipment Application

Inland Marine

Contractor's Equipment Application

Inland Marine Department

1. Please answer all questions. If any section does not apply, please indicate with “Not Applicable” OR “None”.
2. If there is insufficient space to complete your answer for a particular question please use and attach as many additional pages as required to include any supplementary information.

APPLICATION FORMS PART OF THE POLICY

The Applicant(s) submission of this application including any additional information does not obligate the Applicant to buy insurance nor are we obligated to sell or offer insurance upon any specific terms requested. If insurance is effected, this Applicant’s application, including any additional information provided, all will attach to and form part of the policy that is issued.

Completion of this form does not bind coverage. Applicant’s written acceptance of an insurance company’s quotation and company’s written agreement to be bound are required to bind coverage and issue policy.

Contractor's Equipment Application

1. a) Name of Applicant:
b) Did the Applicant change names in the past 5 years? / Yes No
If so, please list the Named Insured(s) the Insured operated under:
2.Operating as:
3.Address (Head Office):
4.Specify exact nature of operations:
5.Area(s) of Operation:
6.Schedule of equipment: (attach list if needed):
Year / Make / Model / Serial Number / Amount of Insurance
7.Insured has been engaged in this type of operation: / years

8.Is equipment subject to the following hazards? (Explain in detail):

(a) Transportation by water:

Number of trips per year:
Type of vessel(s):

Travelling between:

Maximum value shipped any one time: $
(b) Operation from barges or other floating conveyances:
(c) Ice and Muskeg:
(d) Others unusual to general operation of applicant:

9.What percentage of total work performed includes the following:

Percentage of Total Work

Logging Operations
Land clearing or brush cutting
Strip mining
Underground mining
Bridge Construction
Dam Construction
Road Construction
Oilfields
Other

1. When equipment is transported from site to site what percentage is carried by:

Percentage

own trucks
common carriers
11.Is the equipment used solely by the Applicant? / Yes / No

12.If equipment is leased to others, complete the following and attach a copy of the Applicant's standard lease agreement.

(a) Equipment is leased on: / Long term leases short term leases
(b)Maximum value of equipment on lease at any one time: / $
(c)Average value of equipment on lease at any one time. / $
(d)Equipment leased with operator:
(e) Equipment leased without operator:

13.If equipment is leased to others describe operations of lessee:

14.Maximum accumulation of equipment at any one site which may be subject to catastrophe: / $

15.Advise full construction, fire prevention and common or special hazards of all repair and maintenance garages or storage garages in which equipment is repaired or stored:

(a) Address

(b)Construction

(c) Fire prevention

(d) Common or special hazards.

16.Is any spray painting or welding conducted in the building(s)? (Attach diagram and photographs if available)

Yes / No
17.Maximum accumulation of equipment located within repair and maintenance garage or storage garages / $

18.If equipment, when not in use, is stored in open, is open area

(a)Fenced?
(b)Locked?
(c)Under watchman supervision?
19.Is heavy equipment equipped with approved extinguishers? / Yes / No
20.Are maintenance and overhauls done on a scheduled basis? / Yes / No

21. What is the lnsured's reputation in the business and financial community?

22.List all losses (insured or uninsured) occurring within the past five years providing dates, details and amounts.

Please show the gross loss(s) prior to the application of any deductibles:

Date of Loss / Cause / Amount

23.Has any Insurer cancelled or declined to provide this type of insurance to the applicant? If so, explain

Yes / No

Name(s) of previous Insurer(s) in the past 5 years:

24.Does the amount to be insured represent the applicant's entire equipment schedule? / Yes / No
Signed: Applicant
Authorized Signature Position
Date
Broker:
Office:

** A signed application is required upon binding **

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