Quote Loggers Broad Form Insurance

1Business Info.

2Locations

3Operations

4Insurance Limits

5Certificate Holders

6Insurance History

7Driver Info

8Vehicle Info

9Equipment

1010

1111

1212

1313

Section - Business Basic Information

Business Formation Type*

DBA (doing business as name)

Business Name

How many years in business under this name?

New / less than one year

One to three Years

Over three years

How many years "experience" do you have in this business?

Name of individual completing this form

First Last

Are you "First Named Insured" that makes the purchasing decision?

Select yes, if you are the signor and authorized representative responsible for insurance information and purchasing. Sign no if you are not. If not, prove the First Named Insured below.

Yes

First Named Insured

Phone

Enter Email Confirm Email

Section - Locations Owned, Rented or Leased

It is vital that all locations be declared

How many locations do you own, rent or lease?*

If you have more than one location we will ask you to input the locations in another section of the questionnaire. Thank you for your cooperation.

Section - Locations

Location	Actions

There are no Entries.

Maximum number of entries reached.

CHECK BOXE(S) SELECT QUOTE TYPE(S)

Check those boxes for which you want a quote

Click check boxes for lines of insurance to quote. Coverage is not bound by submission of form.

General Liability

Loggers Broad Form

Commercial Auto

Additional Insureds

Tree Contractor GL

Inland Marine / Equipment

Pollution

Workers Compensation

Trucking / Log Hauling

Property / Buildings

Directors & Officers E & O

Forest Consultant Professional Liability

SELECT ACTIVITIES PERFORMED DIRECTLY OR SUB-CONTRACTED

Select activities you will perform throughout the year as a "projection" of overall activities. At the end of the year there is be a reconcillation of "actuia" activies and the percentage of payroll assocaited with each activity.

Please 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

Other

PAYROLL - SELECT "ACTIVITIES" YOU PERMORM OR SUB-CONTRACT

Guestamation at percent of activites and payroll for the policy period. 12 months during the insurance term.

Tree Falling

Est. overall 12 month payroll

Tree Trimming %

Mastication %

Log Hauling %

Slash Burning %

Residential Tree Work %

100% on Forest Lands

Work Near Power Lines %

Work For Utility Companies %

Portable Sawmill Work %

Sawmill (not portable) %

Manufacturing %

Timber License /Vendor license (if none type "none"

Please provide your State/County license or vendor number

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 perform

Are 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 lost

Please call (209) 223-1870 and leave us your phone number and a good day & hours to call

Federal Employer ID#

Are you a member of any other trade Associations or Organizations?

Associated Logger of California

The Louisiana Forestry Association

Other

Please provide the name

Primary Office Phone

Mobile / Cell Phone

Enter Email Confirm Email

Website

Select Business type using dropdown menu

1. Name of Owners/Officers/Partners

First Last

1. Title

1. % Ownership

2. Title

2. % Ownership

Tick the check box to add more

Add More Owners/Officers/Partners

Mail Address

Street Address Address Line 2 City State ZIP Code

Are you currently insured or have you had insurance recently?

Yes

Narrative of your operations.

Please explain "other"

Financial and Experience Information

What is your standing with your past insurance carrier(s)

Total Years experience

Have you or a subsidiary had a bankruptcy in the last five years?

Yes

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 Structures

Building 1

Estimated Year of Construction

Building 1. Occupied or Vacant

Occupied

Vacant

Name or reference for building 1

Bldg 1 squarefootage

"If owned" - Built of Construction Material Type

What is the physical address of Building 1 in Alabama?

Street Address Address Line 2 City State ZIP Code

"If over 14 years old" Building Updates & Construction

Please 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 operations

Limits 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

$5,000,000 per occurrence / $10,000,000

Excess Umbrella with higher limits

Please input the desired Excess Liability Limits

Logger Broad Form

Payroll Estimates for the Next 12 months

Of 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 employees

Log Road Building

Subcontract Logging

Subcontract Logging "Hauling"

Truck Driver Payroll

Other Payroll

What percentage of time are Owners/Officers/Partners active at job site?

Your Activities / Operations

Areas of operations (States, Counties, Towns or Regions)

Do you own the land upon which you or others are operating?

Yes

Your response was "No"... Are all required permits in place with appropriate authorites?

Yes

Is there a signed contractor with the owners?

Yes

What precautions do you take to prevent trespassing onto other land?*

Please describe your methods. For example, use of GPS mapping software, walk-throughs, ect.

What "methods" do you use to determine and identify trees for cutting?*

Inland Marine for tools and equipment coverage

List all heavy equipment. Include year, make, model and estimated current value

General Liability

Limits of Liability

Workers Compensation

Name of current insurance carrier for workers compensation

Commercial Auto / Transportation

Name of current commercial auto carrier

Driver Informaion

Driver name

Vehicles & Trailers

Year, Make and model

Additional Insured(s)

Current Insurance

Please feel free to upload your current policies for review and please include your loss runs for each policy type.

Thank you. Please note coverage is not bound

I understand this is just a quote

I need coverage now!

File upload

Upload your .pdf files.

Drop files here or

Accepted file types: pdf, Max. file size: 256 MB, Max. files: 24.

Loggers Broad Form Insurance Quote

Primary Package Form for Multiple quotes on various lines of insurance

Section - Business Basic Information

Section - Locations Owned, Rented or Leased

CHECK BOXE(S) SELECT QUOTE TYPE(S)

SELECT ACTIVITIES PERFORMED DIRECTLY OR SUB-CONTRACTED

PAYROLL - SELECT "ACTIVITIES" YOU PERMORM OR SUB-CONTRACT

Please call (209) 223-1870 and leave us your phone number and a good day & hours to call

Financial and Experience Information

Buildings and other Structures

Building 1

"If over 14 years old" Building Updates & Construction

Please select the liability limits required by your operations

Logger Broad Form

Payroll Estimates for the Next 12 months

Your Activities / Operations

Inland Marine for tools and equipment coverage

General Liability

Workers Compensation

Commercial Auto / Transportation

Driver Informaion

Vehicles & Trailers

Additional Insured(s)

Current Insurance