General Liability InsuranceInsurance Quotes What is your requested effective Date? ("need by date"" Date Format: MM slash DD slash YYYY CHECK THE BOXES BELOW TO SELECT THE TYPES OF INSURANCE YOU WOULD LIKE TO A OBTAIN QUOTE(S) ON.Please "tick" the check boxes to indicate to us the Lines of Insurance to quote General Liability Only Loggers Broad Form Only Both GL & LBF Commercial Auto Tree Contractor GL Inland Marine / Equipment Pollution Workers Compensation Trucking / Log Hauling Property / BuildingsCHECK OFF ALL ACTIVITIES YOU PERFORM DIRECTLY OR THAT YOU SUB-CONTRACT OUT TO OTHERS TO DO FOR YOUPlease check all operations/activity performed directly Tree Falling Tree Trimming Mastication Log hauling Slash Burning Residential Tree Work 100% Forest work Work near Power lines Work for Utility companies Portable Sawmill Work Sawmill (not portable) Manufacturing Log Road Building Skidding Blasting/Use of Esplosives Wood Working Use of Aircraft/Helicopter/Watercraft Build Bridges, Tunnels or Dams OtherNEXT, BASED UPON THE "ACTIVITIES" YOU SELECTED "ESTIMATE HOW MUCH 'PAYROLL' WILL BE PERFORMED IN EACH KIND OF WORKWe realize no one knows exactly but please provided some estimates. For the owner of the company use a figure of $33,600 regardless of how much you make. For example, one owner and one employee. Employee payroll 35,000. You would use total payroll of $68,600. Some rating bases will vary and your agent will explain to you which rating bases we use for your quote.Tree Falling %Tree Trimming %Mastication %Log Hauling %Slash Burning %Residential Tree Work %100% on Forest LandsWork Near Power Lines %Work For Utility Companies %Portable Sawmill Work %Sawmill (not portable) %Manufacturing %Log Road Building %Skidding %Blasing / Use of Explosives %Wood Working %Aircraft/Helicopter/ Watercraft Use %Construct Bridges, Tunnels or Dams %Other %You marked "other" for activities. Please describe the other kinds of work you performAre you all done with this section? If you need help call us we will go though this process with you. Call (209) 223-1870 Yes, I am good with my responses I am not sure please call me when I am done No, I am lostPlease call (209) 223-1870 and leave us your phone number and a good day & hours to call Contact, Business and Entity InformationName Person Completing this formPerson, not the business nameLegal Business NameIf no dba then individual nameTimber License /Vendor license (if none type "none"Please provide your State/County license or vendor numberFederal Employer ID#Are you a member of any other trade Associations or Organizations? Associated Logger of California The Louisiana Forestry Association OtherPlease provide the namePrimary Office PhoneMobile / Cell PhoneEmail Enter Email Confirm Email Website Business Entity TypeHow is your business entity formed?Please select from this listIndividual / SoleproprietorhipIncorporatedLimited Liability Corporation / LLCGeneral Partnership1. Name of Owners/Officers/Partners First Last 1. Title1. % Ownership2. Name of Owners/Officers/Partners First Last 2. Title2. % OwnershipTick the check box to add more Add More Owners/Officers/PartnersPlease add all additional Owners/Officers/Partners names, title and percent of ownershipMail Address Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Are you currently insured or have you had insurance recently? Yes NoNarrative of your operations.Please explain "other" Financial and Experience InformationWhat is your standing with your past insurance carrier(s)Please selectAll premiums for past and current audits paid currentAll audits paid but have not been audited for this expiring periodIn collections from unpaid / disputed auditTotal Years experienceHave you or a subsidiary had a bankruptcy in the last five years? Yes NoYears of ExperienceYears as business owner(s) Based on the States in which you operate please select which States have buildings such as offices, storage yards, or warehousing Alabama Idaho Michigan New York Tennessee Alaska Illinois Minnesota North Carolina Texas Arizona Indiana Mississippi North Dakota Utah Arkansas Iowa Missouri Ohio Vermont California Kansas Montana Oklahoma Virginia Colorado Kentucky Nebraska Oregon Washington Connecticut Louisiana Nevada Pennsylvania West Virginia Delaware Maine New Hampshire Rhode Island Wisconsin Florida Maryland New Jersey South Carolina Wyoming Georgia Massachusetts New Mexico South Dakota Other Hawaii Buildings and other StructuresIn the State of Alabama "check" all "types" of structures needing property insurance. Later in this application we will as about what types of coverage is needed, use and ownership/rental/lease questions. Office(s) Storage Yard(s) Warehouse(s)Building 1Estimated Year of ConstructionBuilding 1. Occupied or VacantOccupiedVacantVacant since what date?Name or reference for building 1Bldg 1 squarefootageBuilding 1 Occupancy TypePlease selectOwnLease / rent"If owned" - Built of Construction Material TypePlease selectWood FrameSteel FrameManonryCombination Steel, wood, masonryWhat is the physical address of Building 1 in Alabama? Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code "If over 14 years old" Building Updates & ConstructionApproximate Age of Roof and type of materialPlease state year of updates to electrical 'if any"Please state year of plumbing "if any"Please state year of heating updates "if any" Please select the liability limits required by your operationsLimits of base policy for Loggers broad form (and general liability if quote for gl requested) $1,000,000 per occurrence / $1,000,000 aggregate $1,000,000 per occurrence / $2,000,000 aggregate $2,000,000 per occurrence / $2,000,000 aggregate Excess Umbrella with higher limitsPlease input the desired Excess Liability Limits Logger Broad FormPayroll Estimates for the Next 12 monthsOf our total payroll including owner provide "estimates" in $dollars$. (NOTE: For the owner use a standard of $33,600. for example 50% logging adn 50% road building divide the owner payroll of $33,600 between the two categories) For employees payroll use actual payroll estimates.Logging on "your land"Logging (performed by owner on others land)Logging by employeesLog Road BuildingSubcontract LoggingSubcontract Logging "Hauling"Truck Driver PayrollOther PayrollWhat percentage of time are Owners/Officers/Partners active at job site? Logging OperationsAreas of operations (States, Counties, Towns or Regions)Do you own the land upon which you or others are operating? Yes NoYour response was "No"... Are all required permits in place with appropriate authorites? Yes NoIs there a signed contractor with the owners? Yes NoWhat precautions do you take to prevent trespassing onto other land?What "methods" do you use to determine and identify trees for cutting? Inland Marine for tools and equipment coverageList all heavy equipment. Include year, make, model and estimated current value General LiabilityLimits of LiabilityPlease select$1,000,000/$1,000,000$1,000,000/$2,000,000$2,000,000/$2,000,000$3,000,000/$3,000,000 Workers CompensationName of current insurance carrier for workers compensation Commercial Auto / TransportationName of current commercial auto carrierDriver InformaionDriver nameVehicles & TrailersYear, Make and modelThank you. Please note coverage is not bound I understand this is just a quote I need coverage now! We cannot bind coverage with this application at this time. Your application will be reviewed and you will be contacted.