Riggers Liability Application

  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.

SECTION A – Company Information

Company name:

Company address:

Contact name:

Office phone number:

Website:

Policy term: FromTo

Annual income:
Last Year:
Estimate for current year:

Please describe the nature of your business and the number of years you have been in business.

Please provide contact information for inspection purposes.

Name of contact:

Phone number:

E-mail Address:

SECTION B – General Information

  1. Describe the location and types of projects, including the terrain and conditions, where the equipment is usually operated:
  2. What types of jobs have you performed during the past twelve months? And how many?
  3. What are the average value of the jobs performed during the past twelve months and the value for the five largest jobs performed during the period?
  4. Provide information if the equipment is used underground or upon watercraft:

Name / Years of Experience / Accident Record
  1. Provide information if the equipment is used for tandem lifts:
  2. What is the number of year of experience of each operator? Provide an accident record for each:
  3. What is the type of training provided to the operators and how often?
  4. Are all operators licensed?
  5. Can all operators read a load guide?
  6. What are your operating safety rules, how are they provided to the employees, and how are they enforced?
  7. Are background checks of employees made?
  8. Is a preventive maintenance program provided for the equipment, and who provides it?
  9. Are cranes leased or rented to or from others with insured’s operators?
  10. Are cranes leased or rented or from others without insured’s operators?

SECTION C – Equipment Description

Item number:

Description of Equipment:

Manufacturer:Model:Serial Number:

Year Built:Lift Capacity: Length of boom:Lift Height:

Item number:

Description of Equipment:

Manufacturer:Model:Serial Number:

Year Built:Lift Capacity: Length of boom:Lift Height:

Item number:

Description of Equipment:

Manufacturer:Model:Serial Number:

Year Built:Lift Capacity: Length of boom:Lift Height:

SECTION D – Limits of Insurance and Deductible

Coverage while at any one job site:

Deductible:

SECTION E – Additional Information

Which insurance companies have you used in the last five years?

Please provide further information on losses of the last five years.

Applicant name:Title:

Signature:Date:

Producer Name:Brokerage:

Address:Telephone Number: