GAS & ELECTRIC UTILITY APPLICATION SUPPLEMENT

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1 Chubb Group of Insurance Companies 15 Mountain View Road, Warren, New Jersey GAS & ELECTRIC UTILITY APPLICATION SUPPLEMENT GENERAL INFORMATION Applicant Name: A. Applicant is: Investor Owned Utility Municipally Owned Utility Board Municipally Owned Utility District Rural Electric Cooperative Other B. Please comment on management, its experience, reputation, and years of experience: C. Applicant operates the following: Light and Power Authority Gas Utility Sewer Utility (Check all that apply) Telephone Utility Other Municipal Operations Water Utility Other D. Service Territory What cities, towns or villages do you serve? Name Population COVERAGES Please check coverages and limits desired COVERAGE LIMITS OF INSURANCE Property* General Liability* Auto* Workers Compensation* Pollution* Umbrella* Other *Complete ACCORD application or equivalent Form (Rev ) Page 1 of 5

2 ELECTRIC UTILITY SECTION I. A. The electric utility s annual sales are broken down as follows: Type of No. of Amount of Gross Customer Customers Electricity Sold Receipts Residential KWH $ Commercial KWH $ Industrial KWH $ Wholesale KWH $ Transportation KWH $ Totals KWH $ B. List any customers accounting for more than 5% of average output. II. Capacity A. Total Generating Capacity (KWH) B. Peak Demand 1. Maximum peak last year 2. Estimated peak this year C. Capacity of largest operating unit D. How many days of operation at 80% or more of capacity: 1. Last year 2. Estimate current year III. Facilities A. What percentage of total generating capacity is fueled by: 1. Water power 2. Coal 3. Oil or Gas 4. Nuclear 5. Other B. High Voltage Transmission: 1. Number of miles 2. Miles in densely populated areas 3. Miles in forested areas C. Low Voltage Transmission: 1. Number of miles 2. Miles in densely populated areas 3. Miles in forested areas Page 2 of 5

3 IV. Inter-Ties A. Does the company participate in a regional grid or power pool? B. Was the company a net importer or exporter of pooled power last year? C. Are spinning reserves maintained? What is the average percentage of spinning reserve to total output? V. Interruption or Black-Outs A. List any major interruptions during last three years including cause, number of customers affected and length of outage: VI. Construction - Maintenance A. List major new facilities to be added this year. B. Net addition to capacity scheduled for current year: C. Is there a comprehensive plan for replacement of aging facilities including distribution lines? D. Is there any construction of transmission on distribution lines contemplated? If so, please describe. E. Are up-to-date system maps maintained? 1. Do they include dates of replacements and major repairs? 2. Are main shut-off and regulating controls indicated? F. Is there any construction on maintenance contracted out? If yes, please describe type of associated cost. G. Is the applicant a part of any mutual assistance agreement? Yes No. If yes, please describe. H. Any DSM Program in place? Yes No. If yes, please describe. Form (Rev ) Page 3 of 5

4 GAS UTILITY SECTION I. The Gas Utility s Annual Sales are broken down as follows: Type of No. of Amount of Gross Customer Customers Gas Sold (MCF) Receipts Residential $ Commercial $ Industrial $ Wholesale $ Transportation $ Totals $ II. Pipeline System A. Number of Miles B. Construction Type (# Of Miles) 1. Unprotected Steel 2. Protected Steel 3. Plastic 4. Cast Iron 5. Copper 6. Other Transmission Gathering Mains III. Leak Remediation A. Percent of unaccounted for gas. If greater than 3%, please explain B. Total leaks What were causes? C. Are gas leakage surveys conducted within business district annually? Yes No D. Are gas leakage surveys conducted outside principal business areas at least every five years? Yes No E. Does utility check and service annually each valve which may be necessary for safe operation of system? Yes No F. How many of the following classes of leaks were found in the latest surveys (A) and/or (B): Class 1 present disposition Class 2 present disposition Class 3 present disposition G. Who conducted these surveys? H. Methods used. I. What type of instrumentation does operator have for leak detection? Page 4 of 5 Page 4 of 5

5 IV. General Information A. Does utility sell household appliances? Yes No Any sale of used appliances? Yes No Amount of appliance sales in last fiscal period. $ B. What type of appliance sold? Does utility repair and/or service appliances or do any other work beyond the customer s meter? Yes No If yes, answer the following: Amount of receipts for such work in the last fiscal year $ C. Any service or repair work subcontracted? Yes No If yes, please indicate type and associated cost. Describe any other operation conducted at any other location: D. Does utility own or operate any peak-shaving plant, complete the following: Address: 1. Gallon Capacity W. G. Fenced? Yes No 2. Surrounding Exposure 3. How many gallons used in the last fiscal period? 4. Age - Approximate 5. Physical condition E. Does utility own or operate any storage tanks? Yes No. If yes, please describe. 1. Number 2. Sizes and capacities 3. Gas pressures carried 4. Construction - Are all pressure tanks constructed in accordance with ASME or Apt Unfired Pressure Vessel Codes, U66 or U69? If they are not, comment in detail and give location on each such tank. 5. Condition: 6. Inspection Service A. Are all tanks insured? B. If yes, by whom: C. Comment on any regular internal and external inspection service by qualified pressure vessel inspector. Form (Rev ) Page 5 of 5

6 The undersigned persons declare that to the best of their knowledge the statements set forth above and in any attachments to this APPLICATION are true and correct, and that every reasonable effort has been made to obtain sufficient information to facilitate the proper and accurate completion of this APPLICATION. The undersigned agree that if any significant change in the condition of the Applicant is discovered between the date of this APPLICATION and the effective date of the policy which would render this APPLICATION inaccurate or incomplete, notice of such change will be reported in writing to the COMPANY immediately and, if necessary, any outstanding quotation may be modified or withdrawn. The undersigned persons understand and further agree that the completion and signing of this APPLICATION neither binds the COMPANY to sell nor the Applicant to purchase the insurance. PLEASE NOTE: ONLY DULY APPOINTED AGENTS OF THE COMPANY AND LICENSED BROKERS ARE AUTHORIZED TO SOLICIT APPLICATIONS FOR COVERAGE. AGENTS AND BROKERS ARE NOT AUTHORIZED TO BIND COVERAGE. NO COVERAGE SHALL BE PROVIDED UNLESS THE COMPANY ACCEPTS THE APPLICATION AND BINDS THE COVERAGE. False Information: Any person who, knowingly and with intent to defraud an insurance company or other person, files an Application or insurance containing any false information, or conceals for the purpose of misleading, information concerning any material fact thereto, commits a fraudulent insurance act, which is a crime. False Information (California Only): For your protection, California law requires the following to appear on this form: Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. False Information (Colorado Only): It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company, who knowingly provides false, incomplete or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds, shall be reported to the Colorado division of insurance within the department of regulatory agencies. False Information (Florida Only): Any person who, knowingly and with intent to injure, defraud, or deceive any insurer, files a statement of claim or an Application containing any false, incomplete, or misleading information, is guilty of a felony of the third degree. 1

7 False Information (Louisiana Only): Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. False Information (Maine Only): It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. False Information (Nebraska Only): files an Application for insurance containing any false information, or conceals for the purpose of misleading, information concerning any material fact thereto, commits a fraudulent insurance act, which is a crime, where such person subsequently submits a claim. False Information (New Mexico Only): Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties. False Information (New York Only): files an Application for insurance containing any materially false information, or conceals information concerning any material fact thereto, for the purpose of misleading, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. False Information (Ohio Only): Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. False Information (Oklahoma Only): WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. 2

8 False Information (Oregon Only): files an Application for insurance containing any false information, or conceals for the purpose of misleading information containing any material fact thereto, may be guilty of a insurance fraud. False Information (Pennsylvania Only): files an Application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any material fact thereto, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. False Information (Vermont Only): files an Application for insurance containing any false information, or conceals for the purpose of misleading, information concerning any material fact thereto, commits a fraudulent insurance act, and the policy may be voided. False Information (Virginia Only): It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the insurance company. Penalties include imprisonment, fines, and denial of insurance benefits. 3

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