Crane and Heavy Equipment Insurance-Intake Form

Crane and Rigging Submission Form

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GENERAL INFORMATION

Business Type

Business Start Date

Do you use your personal name for your business name or do you have a DBA?

I use my personal name

I have a DBA

Full Legal Name of Business Owner

DBA Name?

What's Your Business Name?

Do you use a DBA?

Yes

What's your DBA?

Do any additional business names or subsidiaries need coverage?

Yes

Name of Subsidiary

Describe Operations of Subsidiary

Do you have any of the following?

DOT #

MC #

What's your DOT # ?

What's your MC # ?

Are any filings needed?

DOT Filing

MC Filing

Other Types

Please describe other Filings Needed

Do you currently have insurance?

Yes

Yes, but need to add coverage

No, Planning for New Venture

Has your insurance ever been cancelled or non-renewed?

Yes

Yes, but due to outside factors

What was the reason for cancellation or non-renewal?

Your Business Location Address (No PO BOXES)

Do you have a different Mailing Address?

Yes

Mailing Address

Full Name of Contact Person

Phone Number (mobile number preferred)

Email Address

What Effective Date should we use on the Quote?

Types of Coverage Requested

General Liability

Commercial Automobile

Rigger’s Liability (coverage for the actual ‘thing’ that is being lifted/hoisted)

Equipment or Inland Marine

Workers Compensation

Umbrella/Excess Liability

Hired and Non-Owned Auto Liability

Not Exactly Sure

Select the different activities applicable to your Business (select all that apply)

You use your own equipment when others hire you

You rent out your equipment without you as an operator (Bare Crane Rental)

You Subcontract work to others or use non-employees

Millwrighting – and/or Installation, Dismantling, and Repairing of Heavy Equipment

Rigging (securing the load for hoisting)

Steel Erection

Heavy Hauling

Other Activities

Describe your other business activities

Crane Rental with Operator – Guesstimated Annual Sales

Crane Rental with Operator – Guesstimated Annual Payroll

do not include owner payroll

Bare Care Rental – Guesstimated Annual Sales

Bare Care Rental – Guesstimated Annual Payroll

do not include owner payroll

Millwrighting – Guesstimated Annual Sales

Millwrighting – Guesstimated Annual Payroll

do not include owner payroll

Rigging – Guesstimated Annual Sales

Rigging – Guesstimated Annual Payroll

Steel Erection – Guesstimated Annual Sales

Steel Erection – Guesstimated Annual Payroll

Does Steel Erection Include and Fabrication or Welding?

Yes

Heavy Hauling – Guesstimated Annual Sales

Heavy Hauling – Guesstimated Annual Payroll

Is Hauling in conjunction with Crane Operations?

Yes

Other Activities – Guesstimated Annual Sales

Other Activities – Guesstimated Annual Payroll

Describe Typical Items Lifted

Are you ever responsible for servicing or repairing the property or equipment of others?

Yes

Sometimes

Describe typical items serviced and repaired for others:

DOES YOUR OPERATION INCLUDE WORK FOR ANY OF THE FOLLOWING :

Select all that apply

Use of Non-Owned, Rented, Borrowed, or Leased Equipment

More than 5% of road and/or bridge work

You allow others to rent or borrow your equipment ‘Bare Equipment Rental’

You are responsible for safeguarding the product or ‘item’ that is being hoisted – Rigger’s Liability

Work Not on Firm Ground

Hot power line or utility work

Demolition

Tandem Lifts

Personnel Buckets

Oil Field Work

Around Explosive Materials on Job Site

Tower Crane Use

New York Operations

Regarding the use of Personnel Buckets, what type of jobs are typically performed?

Are you or any of your employees ever 'in' a Personnel Bucket?

Yes

What percentage of your employees are in the bucket?

Are Subcontractors or Non-Employees ever 'in' a Personnel Bucket?

Yes

What percentage of subcontractors or non-employees are in the bucket?

Do you obtain Proof of Workers Compensation Insurance when Subcontractors or Non-Employees are used in Personnel Buckets?

Yes

OIL FIELD WORK

Is any Oil Field Work done over Open Wells?

Yes

Is any Oil Field Work ever done over active wells?

Yes

TOWER CRANE OPERATIONS

Please describe typical jobs when Tower Cranes are used

NEW YORK BASED OPERATIONS

What percentage of your operations are conducted in the State of New York?

NON-OWNED, RENTED, LEASED, OR BORROWED EQUIPMENT USAGE

Describe the Equipment Rented or Borrowed from Others

Guesstimated Annual Costs to Borrow or Rent this Equipment

BARE EQUIPMENT RENTAL

Bare Equipment Rental – Select All that Apply

Verify operations of the user/operator?

You obtain a signed rental contract

Yo do not obtain a signed rental contract

Pre-Rental Inspections are Completed prior to all rentals

Certificates of Insurance are obtained

You are named as an additional insured on all Certificates of Insurance

The Rental Agreement has a Hold Harmless Clause

5 Year Record Keeping Practices are Observed

Please upload a sample of the rental rental agreement used

Max. file size: 16 MB.

Is there a reason you do not have renters sign an agreement?

SUBCONTRACTING SECTION

Percentage of your annual revenue used to hire Sub-contractors?

Describe the work you typically sub-contract out to others

How many full-time subs operate/drive?

How many part-time subs operate/drive?

RIGGER'S LIABILITY SECTION

Coverage for the item or ‘thing’ that is being hoisted/lifted.

What limit of Insurance is needed for the Rigger's Liability?

What is the average value of any item being lifted?

What is the maximum value of any item being lifted?

Describe items being lifted

CLICK ALL THAT APPLY

You Store or haul items you lift

You haul only in conjunction with the crane operation

OPERATORS & DRIVERS SECTION

Who operates the equipment and/or drives the vehicles?

The owner only

One or multiple employees

Subcontractors

How many total employees do you have?

do not include clerical employees and non-operators

Do you check MVR's of new drivers and operators?

Yes

SAFETY & RISK MANAGEMENT SECTION

Click all safety precautions and risk management tactics your business uses

click all that apply

Employees and Subcontractors are screened for acceptability

Jobs Tickets and/or Contracts are used for each job

use a safety checklist on equipment prior to use

maintain service records for at least 5 years

inspect your slings/chains prior to each lift

inspect the rigging performed by others prior to operating

obtain actual weight of item prior to lift and record on job ticket

Have you ever been cited by OSHA or had a reportable incident?

Yes

Regarding the OSHA incident (s), please explain or describe

REGARDING YOUR USE of SUBCONTRACTORS & NON-EMPLOYEES

Click all that apply

Contract/Service Agreements are used with all SUBCONTRACTORS

You obtain certificates of insurance from all Sub-Contractors naming you as an additional insured

5 Year Record Keeping Practices are Observed

Describe communication techniques employed during lifts

Click all safety precautions and risk management tactics utliized

Employees and Subcontractors are screened to ensure operator competence including driving

Regular Safety Meetings take place

Loss Control & Safety Programs are in place

outriggers fully extended & suitable soil & ground base are checked prior to use

level/boom angle indicators are available and used

load charts used for all lifts

Procedure for crane placement near overhead power lines, including minimum OSHA required clearance

Crews trained in emergency procedures if high voltage contact is made

HIRED & NON-OWNED AUTOMOBILE LIABILITY SECTION

Does your business own any vehicles?

Yes

To your knowledge, do you have more than 1 (one) commercial automobile policy in place?

Yes

Section Break

DOCUMENTS REMINDER

Please upload a sample of the rental rental agreement used

Accepted file types: jpg, gif, png, pdf, Max. file size: 16 MB.