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?

Phone Number (mobile number preferred)

Email Address

Your Business Location Address (No PO BOXES)

Do you have a different Mailing Address?

Yes

Mailing Address

Full Name of Contact Person

Do any additional business names or subsidiaries need coverage?

Yes

Name of Subsidiary

Describe Operations of Subsidiary

Do you operate your business in other states?

Yes

Yes, but minimally

What other states?

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?

What Effective Date should we use on the Quote?

TYPES OF COVERAGE REQUESTED

Click all that apply

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

Does your business own any vehicles?

Yes

BUSINESS ACTIVITIES (including revenue & payroll information)

including revenue & payroll information

SELECT THE DIFFERENT ACTIVITIES APPLICABLE TO YOUR BUSINESS (select all that apply)

You use your own equipment/Crane/Boom 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)

Equipment Servicing and/or Repair

Steel Erection

Heavy Hauling

Other Activities

Describe your other business activities

Annual Revenue – when others hire YOU to use YOUR own equipment/Crane/Boom

Annual Payroll – when others hire YOU to use YOUR own equipment/Crane/Boom

do not include owner payroll

Annual Revenue – Bare Care Rental

Annual Payroll – Bare Care Rental

Annual Revenue – Millwrighting

Annual Payroll – Millwrighting

do not include owner payroll

Does Millwrighting include installation and repair?

Yes

Yes, but minimally

Describe typical items serviced or repaired for others

Annual Revenue – Rigging

Annual Payroll – Rigging

Annual Revenue – Steel Erection

Annual Payroll – Steel Erection

do not include owner payroll

Does Steel Erection Include and Fabrication or Welding?

Yes

Annual Revenue – Heavy Hauling

Annual Payroll – Heavy Hauling

do not include owner payroll

Is Hauling in conjunction with Crane Operations?

Yes

Annual Revenue – Other Activities

Annual Payroll – Other Activities

do not include owner payroll

Describe Typical Items Lifted

Describe typical items serviced and repaired for others:

ADDITIONAL BUSINESS ACTIVITIES

DOES YOUR OPERATION INCLUDE WORK FOR ANY OF THE FOLLOWING :

Select all that apply

Select All

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/Crane/Boom – ‘Bare Equipment Rental’

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

New York Operations

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

PERSONNEL BUCK USE & OPERATIONS

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

What percentage of your overall revenue is generated from the use of personnel buckets?

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

Yes

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

compared to owners/employees

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

Yes

Do you obtain Proof of General Liability 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/Crane.Boom Rented or Borrowed from Others

Guesstimated Annual Costs to Borrow or Rent this Equipment/Crane/Boom

BARE EQUIPMENT RENTAL

Bare Equipment Rental (you rent to other without an operator)

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

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

SUBCONTRACTING SECTION

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

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

Describe the work you typically sub-contract out to others

How many full-time subcontractors operate/drive?

How many part-time subcontractors operate/drive?

RIGGER'S LIABILITY SECTION

Coverage for the item or ‘things’ that are being hoisted/lifted.

Describe items being 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?

CLICK ALL THAT APPLY

You Store or haul items you lift

You haul only in conjunction with the crane operation

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

load charts used for all lifts

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

Yes

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

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

OPERATOR EXPERIENCE SECTION

for both Drivers & Operators

NAME	DOB	DRIVER LICENSE #	STATE	NCCO NUMBER (if certified)	OPERATOR/DRIVER OF BOTH?	ANY PREVIOUS LOSSES, ACCIDENTS, or VIOLATIONS?

LIST ALL OWNED EQUIPMENT, CRANES, & BOOMS

If equipment/crane/boom is attached to a vehicle, list both separately.

YEAR	MAKE	MODEL	VIN # or Serial Number	VALUE

DOCUMENTS REQUESTED

Please upload a sample of the rental rental agreement used

Max. file size: 16 MB.

Please upload a sample of the rental rental agreement used

Max. file size: 16 MB.

Please upload a sample of the services agreement you use with your subcontractors

Max. file size: 16 MB.