WCLA Insurance Agency, Inc Commercial Insurance Questionnaire General Information

Transcription

1 WCLA Insurance Agency, Inc Commercial Insurance Questionnaire General Information Business Name Mailing Address Physical Address (if different) Telephone Number(s)-(and the best time to call) First Named Insured- Please list the person who will be responsible for purchasing the policy, policy changes, and all other related insurance matters: Your business is a: * Sole Proprietorship * Partnership or * Corporation Years in Business - How many years have you been in business? If less than 2 years please list number of years experience in the logging industry Geographical Area of your operations - Please includes the counties in which you generally operate: Description of Operations-Please provide a description of your typical business operations and circle all of the below activities which you perform Contract Cutting/Timber Falling Logging Log Road Construction Log Hauling Forestry Services Firewood Sales Sort Yards Operations Residential Tree Service Saw Milling Operations Quarry/Rock & Gravel Operations Blasting/Demolition Street & Road Construction Excavation & Underground Operations Other

2 WCLA Insurance Agency, Inc Prior Insurance History Please complete the following for the past 5 years: Current Year: Insurance Company Type of Coverage Premium Expiration Date Year Insurance Company Type of Coverage Premium Expiration Date Year Insurance Company Type of Coverage Premium Expiration Date Year Insurance Company Type of Coverage Premium Expiration Date Year Insurance Company Type of Coverage Premium Expiration Date Have any of your previous insurance policies ever been canceled or non-renewed by the insurance company?

3 Statement of Loss History Company: Address: City, State, Zip: Please initial the appropriate statement below and if applicable provide loss details in the area provided. My company has not had any losses during the past 5 years or My company has incurred the following losses during the past 5 years: Date: Type: Amount Paid: Signature of Named Insured Date (or Authorized Representative)

4 ~Request for Loss History~ Previous Agency/Insurance Company: Attn: Address: City, State, Zip: Please forward a copy of my five (5) year loss history, as quickly as possiable, to the following: (Must be currently valued- company issued) WCLA Insurance Agency, Inc. PO Box 2168 Olympia, WA Phone No.: (360) Fax No.: (360) If there have been no losses during the past five (5) years, please issue a statement of no knowen losses. Thank you! Sincerely, Please put your cust name here Date Policy Number Policy Number Policy Number Policy Number

5 WCLA Insurance Agency, Inc General Liability (Please complete this section if you want to receive a general liability/loggers broad form property damage quotation) Who are you currently working for? Describe your controls used to prevent timber trespass, (cutting/removing trees over the property line): Are you performing any residential tree topping or removal operations? If so, what percent of your operations is residential work? Are you performing any burning operations? If so, please describe, including the amount of times per year your burn and what type of controls you have in place while burning: Are you performing any log road building operations? If so, what percent of your operations is log road building? Are you responsible for locating the road? Do you ever use explosives during the course of your operations? If so, please describe: Are you involved in any real estate development operations? If so, please describe and include the total acreage of land owned and used for real estate development: Do you hire subcontractors? If so what type of work do your subcontractors perform? Are you requiring ALL Subcontractors to provide you with certificates of insurance, which display limits of liability equal or greater than your own? Are you requiring subcontractors to provide you as an Additional Insured on their liability policies? Do you ever use Hold Harmless Agreements in the course of your operations? If yes, please describe: Do you provide your employees with benefits, such as medical, dental, life and/or disability insurance?

6 WCLA Insurance Agency, Inc General Liability (Please complete this section if you want to receive a general liability/loggers broad form property damage quotation) Premium Basis- Your general liability and loggers broad form property damage premiums are determined by your estimates of payroll, subcontract, and gross receipts for the upcoming policy period. At the end of your policy period, the insurance company may audit your figures to determine your actual payroll, cost, and receipts, adjusting your annual premium accordingly. Therefore, it is important that the following be completed as accurately as possiable. Please list the names of all of your business owners, partnesr or officers and decribe their duties: Owners, Partners, & Corporate Officers Duties Please provide the number of persons you empolyee in each area and their totals, combined, estimated, gross annual payroll. DO NOT INCLUDE OWNERS, PARTNERS, OR OFFICERS. Type of Insurance No. of Employees Annual Payroll Contract Cutting/Timber Falling Logging/Equipment Operators Log Truck Drivers Forestry ServicesEmployees Residential Tree Service Mechanics in Shop Mechanics at Job Site Saw Mill Operations Street & Road Construction Employees Clerical Employees Other Employess (Describe: ) Subcontractors Subcontract Cutting/Timber Fallers Subcontract Log Haulers Other Subcontract Cost (Describe: ) Other Items Needed to Determine Annual Premium Gross Receipts Derived from Saw Milling Operations Gross Receipts Derived form Quarry Operations TOTAL Gross Receipts from all Operations Total Acres of Vacant Land/Timber Hauling Annual Cost Please list any other items which may need to be included in your general liability quotation:

7 WCLA Insurance Agency, Inc Business Automobile (Please complete this section if you want to receive a business automobile quotation) Please list the type and percentage of commodities you transport: Logs % Other Items (Describe) % Your Own Equipment % Equipment of Others % If hauling equipment of others, what is the value of the most expensive item you haul? and what are your estimated annual gross receipts from hauling for others? Who do you haul for? Do you own vehicles which you do NOT wish to insure? If yes, please provide a description of the of the vehicle and reason why you do not wish to have it insured: Do you have a CC Permit or do you have any state fillings? If so please list your authority number and the EXACT name in which your filling is registered: WUTC OR PUC ICC/FHA Other Permit No. Name Permit No. Name Permit No. Name Permit No. Name Do you regularly travel through any major metropolitan cities? If so, please list cities: What is you annual, combined fleet mileage for the past three years? (Commercial Vehicles ONLY) Current Year Last Year Year Before Last Total Estimate for the Coming Year Describe your automobile preventative maintenance program. Please include if daily inspections are performed and if maintenance records are kept for all trucks. Also, list who is responsible for the repairs and maintenance of your vehicles: Outline your driver screening procedures. Please include the number of years experience you require before hiring, if you are obtaining driving reports, (MVR S), if you require a road test, physical examination, etc.: Average Radius of Operation Maximum Radius of Operation

8 WCLA Insurance Agency, Inc. Contractor s Equipment (Please complete this section if you would like an equipment quotation) Is your equipment operated by you and/or your direct employees? If not, please explain who else will be operating your machinery: Do you own any equipment items that you do NOT wish to insure? If yes, please provide a description of the item and reason why you do not wish to have it insured: Describe your equipment maintenance program. Please include if daily inspections are performed and if maintenance records are kept for all equipment items. Also, list who is responsible for the repairs and maintenance of your equipment: What is the minimum years experience you require of your equipment operators before hiring them? What measures do you take to prevent vandalism and theft of your equipment? What measures do you take to prevent fire? (cool down period, watchman, etc.) Do you ever use your equipment for fire fighting or in burning operations? Note: Premium credits may be given to those items that are fitted with any of previous stated safety features.

9 WCLA Insurance Agency, Inc. Commercial Property (Please complete the following if you would like to receive a quotation for the commercial properties you own, rent, and/or occupy) Location of the building Operations performed inside the building (office, repair shop, rental house, etc.): Age of the building/year built: Construction of the building and roof type (wood frame, metal/pole, brick, etc.): Number of stories/floors in the building: Total square footage of the building: Is the building equipped with any alarm systems or safety features, such as smoke detector, burglar alarm, or sprinkler system? What is Adjacent to the Building? How far to the nearest fire hydrant? Responding fire department? What county are you in? Are you inside city limits? Values (Please provide the following values, where applicable) Value of Building- Cost to rebuild in the event of a total loss Value of Contents Total cost to replace all contents inside $ $ Value of Computer System Cost to replace the following: Hardware Software $ $ In the event of a total loss, approximately how many months would it take to reconstruct your commercial building?

10 WCLA Insurance Agency, Inc. Please check any item below you would like us to explain or need insurance coverage for: General Liability Contractor Equip. Umbrella Property Business Auto Other I warrant that the information contained in this questionnaire has been completed to the best of my knowledge and that no material fact has been omitted which would otherwise affect my application for commercial insurance. I acknowledge that the enclosed information forms the basis of an insurance contact with the insurance company and that any intentionally incorrect or inaccurate responses may void coverage hereinafter provided Signature Date

11 Business Auto Schedule of Vehicles (Please complete this section or attach a current schedule of vehicles) Description of Vehicles (Year, Make, Model, VIN# & GVW) Garaging Location Date Purchased Cost New Current Value Radius Creditor/Loss Payee NOTE: Cost New & Current Value should be completed for all vehicles you wish to insure for physical damage. (Collision, Comprehensive/Specified Perils) Also, don t forget to include a listing of any permanently attached or special equipment (welders, winches, loaders, etc.). together with the current value of each item.

12 Business Auto Schedule of Drivers (Please complete this section or attach a current schedule of drivers) Name of Driver (First, Middle Initial, Last) Date of Hire Date of Birth License Number

13 Contractor s Equipment Schedule of Equipment (Please complete this section or attach a current schedule of equipment) Description of Equipment Serial Number Current Value Creditor/Loss Payee Note: Premium credits may be given to those items that are fitted with safety features.