Equipment and Party RentalSupplemental Application - Universal Marketing and management

Equipment and Party Rental
Supplemental Application

Equipment and Party Rental Supplemental Application

Name Insured :

Date Competed

General Liability

1. Describe any discontinued operations in the last five years:

2. Are there any Gasoline or LP tanks above/below ground?

If yes, describe type, size of tank, and any protection or barriers in place (i.e. chain link fence):

3. Do you rent equipment with an operator?

If yes, describe:

4. Number of years in rental business?

5. Are there operations not related to equipment rental, equipment sales, or hardware sales?

If yes, describe operations and include receipts

6. Does the insured erect scaffolding?

7. Does the insured sell firearms or ammunition?

8. Does the insured sell lumber?

9. Does the insured sell windows and/or doors:

10. Are there any repackaging of products or private labels sold?

Describe:

11. Does the insured rent trucks to the public and/or operate a truck or auto franchise?

General Liability

Schedule of Classifications & Receipts

Est. Annual Revenues

Rental

12. Cranes, Boom Trucks($)

13. Contractor’s Equipment($)

14. Equipment with Operator($)

15. Ladders, Scaffolding($)

16. Personnel Lifts (Man Lifts)($)

17. Homeowners Equipment($)

18. Party Goods($)

19. Tents($)

20. Portable Toilet Rentals – Receipts($)

21. Inflatable bounce houses and slides($)

22. Total Rental Receipts($)

Sales:

23. Sales – New Machinery/Equipment($)

Describe:

24. Sales – Used Machinery/Equipment($)

Describe:

25. Sales – Hardware (includes party goods, tools, small power tools, lawn mowers, chainsaws, etc.)($)

26. Gasoline – Sales)($)

27. Propane – Sales($)

28. Total Sales($)

Service:

29. Service/Repair for others – Receipts($)

30. Service/Repair for others - Payroll($)

31. Septic Tank Pumping – Payroll($)

32. Septic Tank Installation – Payroll($)

33. Lessor’s Risk - Describe:

34. Other operations or services - Describe:

35. Total Revenue($)

Total Revenue:

General Liability – Underwriting (Receipts on ACORD GL must be by location)

36. Do all rental customers sign a rental agreement?

37. Has your rental contract been reviewed by legal counsel in the last 5 years?

38. Are pre-rental inspections and testing completed and documented on the rental agreement?

39. Does the rental agreement include an indemnification provision and a hold harmless clause?

40. Do you require your commercial customers to provide certificates of insurance naming your company as an additional insured prior to renting any equipment?

41. Are copies of the Rental Agreement and Certificate of Insurance kept for a minimum of 4 years?

42. Do you require the rental customers to sign off that they were provided with the operator manual, any manufacturer’s recommended safety equipment, and written operation instructions as well as verbal instructions?

43. If the answer is no to any of the above, would you be willing to implement this into your agreements as soon as possible?

44. Is each rental customer’s driver’s license number, credit card, credit report, or license plate number obtained?

45. Is the rentee advised of responsibility for identifying deficiencies and notifying the insured?

46. Are tie-down straps provided for rental trailers?

47. Is the rentee asked what the trailer will carry?

48. Are any of the following rented:

48a) All terrain vehicles, snowmobiles, personal watercraft, or motorcycles?

48b) Sports equipment?

48c) Interactive games/amusement rides, mechanical rides, or carnival rides?

48d) Inflatable bounce houses, slides, dunk tanks, or tents?

48e) Camper trailers?

48f) Shoring, boring, tunneling, or other mining equipment?

49. Are items for infants and children, including cribs, high chairs, and booster chairs rented?

50. If so, please describe and provide the rental receipts

51. Are camper trailers rented?

52. Are the following rented?

52a) Aerial/Scissors Lifts

# of Items

Max Height

Rental Receipts($)

52b) Towable Booms/Cranes

# of Items

Max Height

Rental Receipts($)

52c) Truck Mounted Booms/Cranes

# of Items

Max Height

Rental Receipts($)

52d) Scaffolding

# of Items

Max Height

Rental Receipts($)

53. Do you provide safety braces, wheel locks, support pins, safety harnesses and safety literature with all cherry pickers, aerial lifts and scaffolding, in accordance with the manufacturer and/or OSHA requirements, for every rental with no exceptions?

54. Do you rent or service aerial lifts?

If yes, do you require the customer to sign that:

54b) They understand an OSHA approved safety harness and belt are required at all times when operating the lift?

54a) They have been trained and understand how to operate the equipment in accordance with the manufacturer’s specifications?

54c) The manufacturer’s recommended safety equipment (including harnesses) is provided or require the customer sign-off that they will provide their own?

54d) Verification that the operator manual was provided?

If yes, describe:

If yes, describe the operations and include the receipts

55. Do you employ counter staff under age 21?

Tent Rental:

56. How many tents are in the insured’s inventory?

57. What is the replacement cost & square footage of the two (2) largest tents?

58. Does the insured have an emergency preparedness plan in place for tents in the event of severe weather conditions?

59. Do you advise the tent rental customer to contact “811” prior to tent installation, so they can locate and mark their underground facilities?

60. Do you require the insured sign that you are not responsible for any damages while installing tents?

Portable Sanitation:

61. Does the insured install or excavate septic tanks or leach fields?

62. Does the insured do any fiberglass repair on portable toilets?

If yes, describe operations:

63. Where does the insured dump the sewage?

63a) In a city or state approved treatment center?

63b) In a non-approved treatment center?

64. Are there any special filings the insured needs to have for his operation (State or Federal IIC #s)?

If yes, describe operations:

65. Is the insured a member of the Portable Sanitation Association International?

Auto:

66. Do you maintain the approved driver files as required by DOT regulations for all drivers with CDL's?

67. Are MVRs obtained on an annual basis for CDL drivers, per DOT regulations?

68. Is a driver application form completed for each employee that drives a service or delivery vehicle/trailer?

69. Are MVR’s checked prior to hiring?

70. Is employment contingent on MVR evaluations, if checked post hire?

71. If no current written Disciplinary Plan is in place, are you willing to implement one?

72. Are accidents investigated with the results shared with the responsible driver? Is corrective action taken on problem drivers?

73. Are any company owned vehicles used for personal use?

If yes, please provide details:

102 e) Other: (Describe)

74. Is there a written policy for personal use of company owned/insured autos/trucks?

75. Do any employees use their own personal vehicles for business uses?

If yes, please describe:

76. Do you require minimum liability limits of $500,000 Combined Single Limit for Personal Auto Policy covering these individuals?

77. Are MVR’s obtained on all family members if there is personal use?

78. Is scheduled maintenance and servicing performed at suggested mileage intervals and by qualified mechanics?

79. Do you retain and review vehicle maintenance logs on a regular basis?

80. Are daily, weekly, or monthly inspections of the autos/trucks performed?

81. Are any non-owned autos or trucks held for repair or storage?

82. Do you haul for others?

If yes, please advise the amount of revenue from this service($):

Inland Marine – Underwriting and Security Measures

83. When renting equipment, do you sell or offer to sell a Loss Damage Waiver

84. Are buildings equipped with central station monitored burglar alarms?

85. Are all locations equipped with a chain link fences, motion detectors, and/or security lighting?

Describe:

86. Does camera surveillance cover the premises inside of the building?

87. Does camera surveillance cover the outside lot?

88. Do exterior lights remain on all night and illuminate all areas of the premises?

89. Are all storage areas at this location secured in such a way that equipment cannot be removed from the premises during non-business hours without causing property damage to perimeter fences, posts, chains, barricades, and/or gates?

90. Are wheel locks used to secure equipment in outside lots?

91. Is a Satellite Tracking System utilized on rental equipment valued over $50,000?

92. Are Certificates of Insurance listing “you” as a Loss Payee obtained from all commercial customers?

93. Total Value of all rental equipment($):

94. Basis of Valuation:

95. Average age of equipment:

96. Deductible:

Other Deductible($)

97. List four (4) largest items of rental equipment:

97a) Description

97a) Value($)

97b) Description

97b) Value($)

97c) Description

97c) Value($)

97d) Description

97d) Value($)

98. What percent of equipment is stored outside?

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Equipment Maintenance

99. Is there a lock-out/tag-out system in place?

100. Is regular maintenance performed on the rental equipment to manufacturer’s specifications?

101. Are modifications made to rental equipment?

102. Is there a ready to rent system:

102a) Visual inspection?

102b) Visual inspection with records retained on large equipment?

102c) Visual inspection with records retained on all equipment?

102d) Visual inspection with records retained on all equipment with equipment tagged?

102 e) Other: (Describe)

103. Is electrical testing equipment used to check for electrical shortages or leakage?

FRAUD AND APPLICANT’S STATEMENT FRAUD WARNING STATEMENTS Knowingly presenting false or misleading information in an application for insurance may be a crime and violation of law subjecting the applicant to criminal and civil penalties. Arkansas, Louisiana, Rhode Island and West Virginia applicants: 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. Alabama applicants: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution, fines, or confinement in prison, or any combination thereof. Colorado applicants: 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 policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder 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. District of Columbia applicants: Warning: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. Florida applicants: 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. Hawaii applicants: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both. Kentucky applicants: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. Maine applicants: 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. Maryland applicants: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. New Jersey applicants: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. New Mexico applicants: 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. New York applicants: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, and any person who, in connection with such application or claim, knowingly makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, damage or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or an insurance company, 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 value of the subject motor vehicle or the stated value of the claim for each such violation. Ohio applicants: Any person who, with 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. Oklahoma applicants: 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. Oregon applicants: Any person who knowingly and with intent to defraud or solicit another to defraud an insurer: (1) by submitting an application or; (2) filing a claim containing a false statement as to any material fact may be violating state law. Pennsylvania Applicants: Any person who knowingly and with intent to injure or defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false, incomplete, or misleading information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties, including imprisonment for up to seven years and payment of a fine of up to $15,000. Tennessee applicants: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. Virginia applicants: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. Washington applicants: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits. Arbitration Statement Applicable to Utah applicants: If the policy will contain an arbitration clause: Any matter in dispute between you and the company may be subject to arbitration as an alternative to court action pursuant to the rules of the (American Arbitration Association or other recognized arbitrator), a copy of which is available on request from the company. Any decision reached by arbitration shall be binding upon both you and the company. The arbitration award may include attorney's fees if allowed by state law and may be entered as a judgment in any court of proper jurisdiction.

SIGNING THIS FORM DOES NOT BIND THE APPLICANT FIRM OR THE COMPANY TO COMPLETE THE INSURANCE. APPLICATION MUST BE SIGNED AND DATED BY AN OWNER, PARTNER OR OFFICER OF THE APPLICANT FIRM.

APPLICANT’S STATEMENT: I, being duly authorized, have read the above application and declare that to the best of my knowledge and belief all of the foregoing statements are true, and that these statements are offered as an inducement to the Company to issue the policy for which I am applying. (Kansas: This does not constitute a warranty).

Authorized Signature:

Title:

Print Name:

Date

Producer’s Signature:

Title:

Print Name:

Date

License Identification Number or National Producer Number: (Florida Producers must Provide License Identification Number)

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