Supplementary Application for

Steel Erectors/Fabricators/Millwrights/

Material Handlers/Crane Operators

Agent Information:Phone:

From:Date:Fax:

Applicant Information

1. Full Name of Insured, including all owned or controlled subsidiaries:

2. Name of person to be contacted in your organization for purpose of inspection:

Phone No Fax No:

3. Current Mailing Address: (Not a PO Box number)

4. Applicant is? (check appropriate box)

 Individual Co-Partnership Corporation Other (Describe)

5. How many years have you been in business under the present name?

6. If less than 3 years, please provide full resume of principals experience or previous name(s) of company.

7. What is your full geographic area of operation, broken down per State:

8. Effective Date Desired:

9.Limits Desired:

Annual Aggregate: / 2,000,000
Products and Completed Ops Aggregate: / 1,000,000
Personal and Advertising Injury: / 1,000,000
Each Occurrence: / 1,000,000
Fire Damage: / 50,000
Medical Payments: / 5,000
Deductible: ($10,000 maximum)

10. Please provide estimated breakdown of annual gross receipts and payroll for the following categories: If this list does not

include all work, for example, Oil Field Servicing, Marine Work, etc.please show on a separate sheet.

Description / Annual Gross
Payroll / Annual Gross
Sales
Millwright work including machinery or equipment installation and repair.
Steel Erection
Crane rental with operator including installation, repair and removal
Rigging if done as a complete and separate operation from any of the above
Crane rental without operator including installation, repair and removal
Heavy Hauling
Scaffolding
Sales of Equipment (attach details)
Other(please specify)
TOTAL

11. What kinds of goods/equipment are typically lifted by your cranes?

12. (a) What is the average on-hook exposure? / $
(b) What is the maximum on-hook exposure? / $

13. Advise if one or few industries or customers provide a large percentage of your work (i.e. Utilities, Marine, Stevedoring, Oil

field, Refineries, Bridges, Commercial Construction, Industrial Plants, etc.)

14. (a)Do you rent out equipment other than cranes? Yes No

(b) What kind of equipment?

(c) / What are the revenues with operator? (including installation, repair and removals)
(d) / What are the revenues without operator? (including installation, repair and removals)

Operators/oilers are: Union Non-Union

# of Operators / # of Oilers / Other Employees

15.

Loss Control and Maintenance / YES / NO
a) Do you have a formal loss control or safety program?
b) Do you have one employee responsible for safety program?
If yes, name:
c) Do you have regular Safety meetings with employees?
d) Do you have safe hiring procedures (or hire through a source that already pre-screens), which
a) outline experience and qualifications for crane operators?
e) Do you have a minimum age for operators?
If yes, what:
f) Do you have an employee training program which includes skill upgrading when experienced
operators are assigned to newer and more sophisticated cranes? Describe.
g) Do you have a written maintenance program? (If yes, attach a copy)
h) Do you have a written form for crane inspections which is used?
i) Do you have an Accident Report form which is used? (If yes, attach a copy)
j) Are cranes Certified Annually?
If yes, by whom:
k) Are Certificates of Insurance required from lessees on bare rentals?
What coverages and limits do your require?
Do you require to be added as an additional insured?
l) Do you order MVR’s on all drivers?

16.How is the adequacy of a crane’s size determined for the job?

Who does this?

17. When leasing without operators how do you verify the qualifications of crane operators used by the leasing firm?

18. Do you ever use helicopters for lifting operations?

If yes, describe

What coverages and limits do you require of helicopter owner? Are you added as an additional insured?

19.(a)Currently Valued Loss History - “Ground Up”, Past five years, 100% Amount of Incurred losses:

Year / Paid Losses / Outstanding / Losses Incurred / No. of Losses
$ / $ / $
$ / $ / $
$ / $ / $
$ / $ / $

(b) Individual Losses in Excess of $5,000:

In order to fully complete this Summary, please provide the following information on a separate sheet.

1) Details and full amount of each loss paid or reserved in excess of $5,000.

2) Details of all open losses.

20.Full Five (5) Year Premium History (should include final audited information when available.)

Year / Limit / Carrier / Premium / Adjustable Revenues / Gross Payroll
21. / Is there any USL & H exposure contemplated? / If so, describe
22. / Are you currently a member of SEAA? / If not, are you eligible?
23. / Is there any professional liability exposure? (i.e. testing) / If so, describe.

24.Please enclose a completed ACORD Commercial Insurance Application and Commercial General Liability Section, both of which are required to complete this application.

Please attach:

  • A list of equipment with values.
  • Financial Statement.
  • Copy of rental contracts or work agreements, including bare rental contract if applicable.
  • Current Experience Modification Worksheet.
  • Loss Control/Safety Program
  • Hiring Procedures

I understand that underwriters shall rely upon the information contained in this supplemental application form to determine the acceptability, rates and coverages proposed. The information contained in this form is accurate and true.

Name (Insured)

Signature Title:

(Agent of Insured)

Date:

1

Alliance National Insurance Agency, Inc., 37 E. Grand Ave., #200, PO Box 278, Fox Lake, IL 60020-0278, 847/587-9040 Phone

11/26/2018-ANI ( WRS\R2CRANE1.app-12/03/96)