HEAVY EQUIPMENT CRANE & RIGGING

HEAVY EQUIPMENT CRANE & RIGGING

SUPPLEMENTAL APPLICATION
Are you filling this out on behalf your client?

YesNo
I am a(n)

Insurance BrokerReal Estate AgentLender / Mortgage BrokerOther
Name*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
Name Insured/Applicant:
Insured Email Address:
FEIN
Physical Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Complete description of operations
IndividualpartnershipCorparationLimited Corp.Joint VentureOther
If OTHER, List description :

Rows	SUBSIDIARIES	NAME	OPERATIONS
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Years in business :
Principal's years of experience :
Please list all of the states where applicant has any operations and percentage :
Average number of field operations employees:
Field operations gross payroll: $ Gross receipts: $
What percentage of work is offshore? %
What percentage of work is wet or marshland? %

Rows	OPERATIONS	PROJECTED ANNUAL PAYROLL	PROJECTED ANNUAL GROSS RECEIPTS
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45
16

Describe any work on or adjacent to bodies of water, including dams and bridge work:
Describe any blasting/demolition and wrecking and/or mining operations:
Describe products/equipment typically lifted:
What is the average on-hook exposure? $
What is the maximum on-hook exposure? $
Does Applicant manufacture and /or fabricate any equipment, parts of accessories for sale, lease, rent or loan?

YesNo
If YES, provide details, brochures and projected annual gross receipts: $
Does Applicant warehouse goods of others?

YesNo
If YES, attach a copy of storage agreement and projected annual gross receipts
Does the Applicant rent/lease equipment from others?

YesNo
If YES, what type of equipment?

Advise the percentage of your applicant's work these customer groups/industries provide to the operations:

Rows	1	2	3	4	5	6
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Please describe the last 3 jobs performed and the largest 2 contracts in place below. Provide a copy of current Work In Progress Report.

Rows	OWNER/CONTRACTOR	TYPE OF WORK PERFORMED IN DETAIL
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5
6

Does applicant engage in any other contracting work?

YesNo
If YES, describe operations and provide revenues:
Does applicant use or rent to others any equipment other than cranes?

YesNo
If YES, what kind of equipment?
What are revenues for rental with operators (non-crane)?
What are revenues for rental without operators (non-crane)?
What percent of work is performed as a sub-contractor working for other companies? %
What percent of work is performed as direct contract with other customers? %
Does applicant ever use sub-contractors?

YesNo

List sub-contracted work and the approximate annual cost associated with each:

Rows	TYPE OF WORK	ANNUAL COST OF SUB-CONTRACTOR
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2
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4

Rigger Liability:
Annual Number of Jobs Usual Duration of Job?
Number of Jobs in Progress?
Does the applicant perform any maintenance work on the equipment of other?

YesNo

Does the applicant perform any maintenance work on the equipment of other?

Rows	DESCRIBE TYPE OF WORK PERFORMED	ANNUAL REVEVUES FROMSERVICE WORK
1
2
3

Is the applicant licensed to Inspect/Certify cranes by their state?

YesNo
Does applicant do inspections/certifications on any equipment of others?

YesNo
Are certificates of insurance required from lessees on bare rentals?

YesNo
Please Provide a copy

Cancelof
Does applicant require additional insured status from lessees on bare rentals?

YesNo
Describe security procedures for crane and vehicle storage:
Please describe any OSHA violations that you have received in the past 5 years and any action taken as a result:
EMPLOYMENT TRAINING & PROCEDURES FOR CRANE OPERATORS
Are applicant's operators Union or Non-Union?

UnionNon - Union
Have any Union members been rejected?

YesNo
How often does applicant refer to the union for new or temporary operators?
Is there a screening/reference process for the new operators?

YesNo
If union shop, describe your screening procedures for any new or temporary employees:
If Non Union, please describe the training program your company provides for employees:
Is training given on an on-going or annual base? Please describe the training below:
Is this training documented?

YesNo
Please provide the following:
Number of operators: Number of oilers:
All other employees:
Is a written test including hand signals, charting of load and radius of use given to all new employees by the applicant?

YesNo
Is an operational test (field test) by type of Crane given to all employees before operator is assigned to that type of Crane?

YesNo
Describe how load weights are determined and by whom?
Does applicant pre-engineer lifts?

YesNo
Who engineers the lift?
Does the applicant perform dual crane lifts?

YesNo
If YES, describe coordination controls used:
EMPLOYMENT TRAINING & PROCEDURES FOR CRANE OPERATORS
Does applicant have a formal loss control or safety program?

YesNo
Is one employee responsible for safety programs?

YesNo
If YES, please provide their name and title:
Does applicant have regular safety meetings with employees?

YesNo
Is there a formal scheduled equipment maintenance program?

YesNo
Is all maintenance documented?

YesNo
Does applicant use a written form for crane inspections?

YesNo
Does applicant use a written accident report form?

YesNo
Are cranes certified?

YesNo
How often? By whom?
Does applicant require certificates of insurance from lessees on bare rentals?

YesNo
Is applicant named as additional insured on Lessees policy?

YesNo
Does management require the following of all lifts?
A policy exists requiring outriggers to be fully extended?

YesNo
Crane leveled before every lift is made?

YesNo
Firm foundation/steel pads under outriggers used?

YesNo
All safety devices required to be operational prior to lift?

YesNo
Load charts clearly posted in cab?

YesNo
Should be Empty:

HEAVY EQUIPMENT CRANE & RIGGING

Rigger Liability:

EMPLOYMENT TRAINING & PROCEDURES FOR CRANE OPERATORS

EMPLOYMENT TRAINING & PROCEDURES FOR CRANE OPERATORS

Does management require the following of all lifts?