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Quote Loggers Broad Form

1Business Info.

2Other Locations

3Loggers Broad Form

4General Liability

5Inland Marine

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?

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

Name of person completing this form

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

FEIN

Federal Employer Identification Number or Social Security Number. (all data encrypted)

Do you have more than one physical location?

Yes

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

There are no Entries.

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

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

Are all required permits in place with appropriate authorities?

Yes

When working with land owners, do you have a signed contract in place?

Yes

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

Tree Trimming

Yes

Log Road Building

Yes

Skidding

Yes

Percent of payroll

Percent Trimming

% Log Rd Bldg

% Skidding

Excavation---Blasting/Use of Explosives---Work in Residential Areas---Slash Burning

Excavation

Yes

Blasting/Use of Explosives

Yes

Work in Residential Areas

Yes

Slash Buring

Yes

Percent of payroll

Percent Trimming

% Residential Work

% Slash Burning

Sawmill Operations---Wordworking---Manufacturing---Use of Aircraft, Helicopter or Water Craft

Sawmill Operations

Yes

Woodworking

Yes

Manufacturing

Yes

Aircraft

Yes

Percent of payroll

Work for Utility Companies --- Work close to Power Lines --- Construction of Bridges, Tunnels or Dams

Work for Utility Companies

Yes

Near Power Lines

Yes

Bridges, Tunnels, Dams

Yes

Other Work

Yes

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

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

Are you named as an Additional Insured on Subcontractors policies?

Yes

Do you retain copies of Additional Insured Certificates for a minimum of 3 years?

Yes

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

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

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

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

Current Limits

Insurance Carrier

Policy Term

Do you require coverage for Oregon Fire Suppression Costs?

Yes

Are you party to a U.S. Forest Services Timber Sales Contract and does it impose liability on you for Fire Fighting Expenses?

Yes

Do you require Additional Insured or Certificate Holders?

Yes

Do you hold any hold harmless agreements?

Yes

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?

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

As a subcontractor, any involvement with the question above?

Yes

Was this work "only" on custom homes?

Yes

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

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

Are there any claims or legal actions pending against you?

Yes

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

Have you or will you perform work related to the following: Refineries, Chemical Plants, Hospitals, Oil & Gas Field or prison Work?

Yes

Will you be performing any Liquid Petroleum Gas work?

Yes

What percentage of your work will be Liquid Petroleum Gas work related?

Please explain the work

Any Janitorial operations?

Yes

Any painting operations?

Yes

Have you or will you work as a construction manager for a fee?

Yes

Are you a residential roofing contractor?

Yes

Do you have other operations other than logging or contracting?

Yes

So you have operations other than logging. Do you have insurance to cover those operations?

Yes

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

There are no Entries.

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

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

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

Anti theft devices?

Yes

Locking gas caps?

Yes

Are fire extinguishers present on every piece of equipment?

Yes

Will equipment be used in water on barges?

Yes

Will equipment be used near water (bridge/dam/levee work)?

Yes

Is a guard or watchperson service employed where the equipment is operated or stored?

Yes

Are all employees (including temporaries) trained to handle the equipment they will operate?

Yes

Are all employees (including temporaries) trained to handle the equipment they will operate?

Yes

AT THE JOB STORAGE SITE

Is there security lighting?

Yes

Are the sites Fenced?

Yes

Are any of the permanent storage areas subject to flooding?

Yes

Are there any hazardous or flamable materials stored in close proximity to the equipment?

Yes

Is any of the equipment stored indoors?

Yes

Is the storage site equipped with a recognized approved central station fire alarm system and fire extinguishers?

Yes

Is the storage sie or any portion of the site equipped with a sprinkler system?

Yes

Are no-smoking rules posted and enforced?

Yes

Are recognized approved central station burglar alarms installed and maintained?

Yes

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

Inland Marine

INSTRUCTIONS

This section is under construction. Feel free to call 209 223-1870200

[email protected]

Phone: (209) 223-1870

Fax: (209) 223-3227

Contact Form
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