Quote Loggers Broad Form Insurance Loggers Broad Form Insurance Check the boxes for the type of insurance you want to receive the quote on below. Need Help Call 209-223-1870 1Business Info. 2Other Locations 3Loggers Broad Form 4General Liability 5Inland Marine 6 7 LOGGERS BROAD FORM, GENERAL LIABILITY & INLAND MARINE Welcome, this questionnaire will allow you to select three "distinct" policies. They are Loggers Broad Form and optionally General Liability and finally, Inland Marine also known as Equipment Insurance What is your absolute need by date?(Required) Note: Smaller Account will take no less than 4 to 5 business days to quote. Much larger accounts can take up to 30 days or more in some instances. MM slash DD slash YYYY Check the boxes that apply to your quote request Loggers Broad Form Insurance General Liability Insurance Inland Marine / Equipment Insurance Wildfire Fire Fighter (go to main menu and look for link) License Number LTO or App # Do you require Certificates for others? Yes No Name of person completing this form(Required) First Last Phone number of "First Named Insured"(Required) Email(Required) Enter Email Confirm Email Name of Business(Required) If you you DO NOT have a "Doing Business As /DBA name, use your first and last name How many years experience does this "entity" have? Website Please select your business formation type Select hereIndividual / SoleproprietorshipCorporation / Inc.General PartnershipLimited PartnershipJoint VentureNon-profit FEIN Federal Employer Identification Number or Social Security Number. (all data encrypted) Do you have more than one physical location? Yes No ADD ADDITIONAL LOCATIONS Add Location Location County Inside City Limits Interest # Full # Part-Time Annual Revenue Sq Ft Occ. Open to Public Total Building Area Any area leased Any Additional Insured Mail Address Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. LOGGERS BROAD FORM SECTON In this section we will be asking some question that are required by "some" of our carriers to evaluate "other operations" that are not specific to logging. How many years have you been in business. If less than one please include in the summary of operation your number of years of experience please Summary of Operations, questions or remarks Feel free to let us know about your operations, ask any question(s) or leave comments. Is there "any" possibility that during the policy period of the insurance quote that you will lease or rent other pieces of equipment Yes No COVERAGES REQUIRED Select Loggers Broad Form Liability Limit Loggers Broad Form limits must be at general liability limits for your information. $300,000 $500,000 $1,000,000 $2,000,000 $5,000,000 $10,000,000 What Deductible would you like? (other than Auto) $1,000 $2,500 $5,000 What Deductible for Auto would you like? $5,000 $10,000 $15,000 PROVIDE PAYRILL ESTIMATES FOR THE NEXT 12 MONTHS FOR THE FOLLOWING: Owner and Employee payroll. Note! Owners are assigned a "fixed" payroll for the purposes of creating a quote of one owner in the field. Use $33,600 for the owner. If there are multiple owners, such as husband and wife where one spouse/ partners works exclusively in the office, use only the owner in the field. $33,600. Most times the Owner's payroll is "split" into several areas, use your best guess as to how much time you will be performing your duties. For example, Logging by Owner, $20,000, Log Road Building $16,000. Employee payroll can be calculated using the same method. For example, if the employee is performing logging and log road building, take his overall projected payroll and place part in Logging by employees and Log Road Building. If you need help please call 209 223-1870. If you registered and logged in you will be able to save and return back to this form. You must registered. You must click on the save and continue later button. Logging (On your lands) Logging (by Owner) Logging (by Emplyees) Logging Road Building Subcontract Logging Subcontract Log Hauling Truck Drivers Other Operations Please provide the percentage of the "time" Owners/Officers/Partners are active at the jobsite LOGGING OPERATIONS List "areas" of operation - States, Counties, Towns or Regions Nature of Operations are they Seasonal or Annual? Seasonal Annual Do you own the land upon which you or others are operating? Yes No Are all required permits in place with appropriate authorities? Yes No When working with land owners, do you have a signed contract in place? Yes No What precautions do you take to prevent trespassing onto others land? What methods do you use to determine boundaries and identify trees for cutting? Activity Felling --- Tree Trimming --- Log Road Building---Skidding Felling Yes No Tree Trimming Yes No Log Road Building Yes No Skidding Yes No Percent of payroll Percent Trimming % Log Rd Bldg % Skidding Excavation---Blasting/Use of Explosives---Work in Residential Areas---Slash Burning Excavation Yes No Blasting/Use of Explosives Yes No Work in Residential Areas Yes No Slash Buring Yes No Percent of payroll Percent Trimming % Residential Work % Slash Burning Sawmill Operations---Wordworking---Manufacturing---Use of Aircraft, Helicopter or Water Craft Sawmill Operations Yes No Woodworking Yes No Manufacturing Yes No Aircraft Yes No Percent of payroll Percent of payroll Percent of payroll Percent of payroll Work for Utility Companies --- Work close to Power Lines --- Construction of Bridges, Tunnels or Dams Work for Utility Companies Yes No Near Power Lines Yes No Bridges, Tunnels, Dams Yes No Other Work Yes No Percent of payroll Percent of payroll Percent of payroll Explain "Other Work" Performed LOGGING OPERATIONS CONTINUED Work in Residential areas, what percentage of logging payroll is derived from Residential payroll? Please state nature of the residental work and al lthe Loss Prevention measured taken to prevent loss Slah Burning, what controls and safeguards are applied to prevent unintended spread of fire? Slash Burning - do you only burn at times or under conditons approved by property state or federal authorities? Yes No Please state nature of the work and all the Loss Prevention measures taken to prevnt loss Manufacturing - please state nature of operations Do you subcontract any of your logging and ancillary work or operations to any third parties? Yes No Are you named as an Additional Insured on Subcontractors policies? Yes No Do you retain copies of Additional Insured Certificates for a minimum of 3 years? Yes No Have you sustained any losses, insured or uninsured, which would have been covered under this policy form of insurance had you carried such a policy? Yes No Explain fully Have thre been any fires or claims for fires occurring in the last 10 years on land while you were working on that land? Yes No Explain the fire claim(s) Has a liability insurance policy ever been cancelled, declined, non-renewed or has any carrier posed any special term? Yes No Explain EXISTING GENERAL LIABILITY INSURANCE If you do not have it you may skip this section and complete our General Liability page. GL is a requirement to purchase LBF. Do you have existing Commercial General Liability Insurance in effect now? Yes No Current Limits Insurance Carrier Policy Term Do you require coverage for Oregon Fire Suppression Costs? Yes No Are you party to a U.S. Forest Services Timber Sales Contract and does it impose liability on you for Fire Fighting Expenses? Yes No Do you require Additional Insured or Certificate Holders? Yes No Do you hold any hold harmless agreements? Yes No Supplemental Contractor Questions We know that these supplemental question may not apply to a majority of Loggers but, some loggers also have a Building Contractor's license. If none or part of these apply please put "0" or "n/a" and we will need you past gross receipts and project gross receipts for the next 12 month. How many years do yo have in the contracting business? How many years of continuous insurance coverage? Contractor License # if other than LTO What percentage of your work if commercial/Industrial? What percentage of your work is residential? What percentage of your work is residential? Gross Receipt for the next 12 months (projected_ Gross Receipt for the prior 12 months or current year ending Gross Receipt for the 2nd year prior Gross Receipt for the 3rd year prior Number of Owners/Partners, Officers - active in the Field Payroll of Employees (excluding owners, officers, partners & clerical Total annual subcontracted costs Describe your largest projects underway or planned for the next year, including values" Have you ever been involved in ground up construction involving condominiums, town houses or single family homes? ? Yes No As a subcontractor, any involvement with the question above? Yes No Was this work "only" on custom homes? Yes No If you have performed work in the past on new custiom homes what iwas the maximum number of homes worked on per year? Will you perform work on single Family Dwelling NEW CONSTRUCTION (not remodel or additions)? Yes No If yes to new dwelling construction, how many new homes will you work on this year? Have you been accused of faulty construction in the past 5 years? Yes No Yes No Are there any claims or legal actions pending against you? Yes No Do you have knowledge or any pre-existing act, omission, event, condition or damages to any person or property that may potential give rise to any future claim or legal action against any entity named in this application? Yes No Have you or will you perform work related to the following: Refineries, Chemical Plants, Hospitals, Oil & Gas Field or prison Work? Yes No Will you be performing any Liquid Petroleum Gas work? Yes No What percentage of your work will be Liquid Petroleum Gas work related? Please explain the work Any Janitorial operations? Yes No Any painting operations? Yes No Have you or will you work as a construction manager for a fee? Yes No Are you a residential roofing contractor? Yes No Do you have other operations other than logging or contracting? Yes No So you have operations other than logging. Do you have insurance to cover those operations? Yes No Additional Insured - If "yes" use the Add Entry Button At a minimum we must have a name and the nature of operations for AI's Add Additional Insured & or Certificate Holders Name of Additional Insured Nature of Work Do you wish to provide more information about this Additional Insured at this time? (optional) Mailing Address Phone Additional Insured Email of Additional Insured Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. General Liability Underwriting Questions Liability Limits Required The General Liability limits and Loggers Broad Form must matched on the "Per Occurrence" limit. For example, if Loggers Broad Form limit is $1,000,000 the "per occurrence" limit on General liability must be $1,000.000 Check the limits you want quoted $1,000,000 per occurrence / $2,000,000 $2,000,000 per occurrence / $2,000,000 aggregate $3,000,000 per occurrence / $3,000,000 aggregate $4,000,000 per occurrence / $4,000,000 aggregate $5,000,000 per occurrence / $5,000,000 aggregate $10,000,000 per occurrence / $10,000,000 aggregate Inland Marine Section Inland Marine / Equipment Proposed Effective Date MM slash DD slash YYYY Must have quote by date MM slash DD slash YYYY Have you declared bankruptcy or been in receivership within the last five years? Yes No Describe location and type of project including the terrain and conditions where the equipment is usually operated Provide detail of Operations if the equipment is used underground, underwater or on watercraft Are any preventive maintenance procedures provided for the Contractor's equipment? Yes No How often is equipment serviced? Who services the equipment? Are bulldozers, loaders, backhoes and other large items equipment "equipped" with tracking devices, such as GPS or etc? Yes No Anti theft devices? Yes No Locking gas caps? Yes No Are fire extinguishers present on every piece of equipment? Yes No Will equipment be used in water on barges? Yes No Will equipment be used near water (bridge/dam/levee work)? Yes No Is a guard or watchperson service employed where the equipment is operated or stored? Yes No Are all employees (including temporaries) trained to handle the equipment they will operate? Yes No Are all employees (including temporaries) trained to handle the equipment they will operate? Yes No AT THE JOB STORAGE SITE Is there security lighting? Yes No Are the sites Fenced? Yes No Are any of the permanent storage areas subject to flooding? Yes No Are there any hazardous or flamable materials stored in close proximity to the equipment? Yes No Is any of the equipment stored indoors? Yes No Is the storage site equipped with a recognized approved central station fire alarm system and fire extinguishers? Yes No Is the storage sie or any portion of the site equipped with a sprinkler system? Yes No Are no-smoking rules posted and enforced? Yes No Are recognized approved central station burglar alarms installed and maintained? Yes No What is the Public Protection Class (PPC rating? Are there any private protection improvements? What is the approximate distance in feet to the nearest fire hydrant? What is the approximate distance in miles to the nearest responding fire department? Is the equipment safety-inspected at regular intervals? Are the transporting vehicle and the tie down equipment checked out before use? For Agency Use Only General Liability and Loggers Broad Form BW - Allianz BW - Lloyds SS - Lloyds Inland Marine BW - Lloyds Safehold BW Allianz
