CONTRACTOR EQUIPMENT APPLICATION

All questions must be answered. Any questions left blank will be deemed to have been answered “NO” or “NOT APPLICABLE”.

Attach an extra sheet if there is insufficient room for you answers

APPLICANT INFORMATION

Type of coverage required:

Contractor Equipment:	YES:	NO:

Logging Equipment:	YES:	NO:

Applicant:

Name of Applicant:
Doing business as:
Address of Applicant:
Year established
**If new venture, please complete new venture section of this form**

Name, addresses and functions of associate or subsidiary companies to be included:

Description of operations:

General areas of operation, topography:

Purpose(s) for which equipment is used?

Is equipment operated in areas subject to muskeg or ice?:

YES:	NO:

Please advise:

Months or periods when equipment is not normally operating:
Location to which equipment is returned when not in use:
Is equipment housed?:	YES: NO:
If yes, estimate maximum value any one time:	CAD $
Is equipment in open?	YES: NO:
If yes, estimate maximum value any one time:	CAD $
If equipment is in open, is area fully enclosed by a fence?	YES: NO:
Does Applicant do any work in mountainous areas?	YES: NO:
Does Applicant do any dynamiting/work at job sites where others might do dynamiting work?	YES: NO:
Will the equipment be used over water, such as bridge building or on barges or jetty work?	YES: NO:
Will the equipment be used on top of or to push burning piles of material such as brush, logs or trash?	YES: NO:

Has an Insurer within the past 5 years refused to renew or cancelled insurance?

YES:	NO:

If yes, please give details:

Please give details on the following:

Current Insurer:
Deductible:	CAD $
Present Rate/Premium:
Expiration Date (dd/mm/yyyy):
Limits

Date from which insurance cover required (dd/mm/yyyy):

Has the Applicant sustained any losses during the past 5 years which would have been covered under this form of insurance if the applicant had carried such a policy?

YES:	NO:

If so, state loss details:

Policy Year	Total Sum Insured at Inception CAD	Insurer	Number of Losses	Loss Description	Amount Outstanding CAD	Amount Paid CAD

Condition of Equipment:

Is each item of heavy equipment equipped with at least one ABC rating fire extinguisher of the following size and type?

20lb dry powder fire extinguisher:	YES:	NO:

9lb halon fire extinguisher:	YES:	NO:

Will any equipment be rented out?	YES:	NO:

If so, is the equipment operated solely by employees of the Applicant?:

YES:	NO:

How often is the equipment serviced and by whom?:

In respect to equipment used in woodland and/or for processing wood products, can you confirm that:

The engine compartments, brake, fuel and tank compartments of all insured equipment will be steam cleaned at least once a month:

YES:	NO:

You have instructed your Operators IN WRITING that:

At frequent intervals during the working day and at the end of the working day the engine compartments and the area between the engine compartments and the protective belly pans of all insured equipment are to be cleaned, removing trash, fuel and lubricant accumulation?:

YES:	NO:

AND

At the end of the working day all the insured equipment if left on site will be at least 50 feet away from other equipment?

YES:	NO:

AND

An operator will remain with the insured equipment for at least 45 minutes after use, until such equipment is cool.

YES:	NO:

Are there any other material facts, within your knowledge, regarding this proposal of insurance, which should be submitted to the Insurers for consideration?:

YES:	NO:

If yes, please advise:

Is the listed equipment the only equipment owned and operated by the Applicant?

YES:	NO:

If no, please give full details of all such other items of equipment and explain why coverage is not required on those items:

Other items of equipment	Reason why coverage is not required

Total Sums Insured (TSI) of all listed equipment:

CAD $

Preferred Deductible:

CAD $

Can you confirm that no one item of equipment has a loan of more than 75% of its current actual cash value:

YES:	NO:

Alternatively, list the loan amount(s) for any item where the loan exceeds 75% of the current actual cash value.

Item	Loan Amount

Please complete below the list of all units for which you require insurance:

Year	Make	Type of Unit	Model	Serial Number	Date of Purchase (dd/mm/yyyy)	Security/Fire Prevention Equipment	Actual Cash Value CAD

NEW VENTURE (to be completed only if a new venture)

Effective date of new venture?: (dd/mm/yyyy)

What is your experience with similar equipment?:

Who did you previously work for?

For how long?:

What area did you work in?:

What equipment did you operate?

How many accidents or losses were you involved in during the past five (5) years?:

Describe the circumstances of the accidents or losses:

With whom do you have a logging contract?:

Who is financing the new venture:

Do you expect to increase the number of your units within one (1) year?:

YES:	NO:

If yes, how many?

DECLARATIONS AND SIGNATURE

I/we hereby declare that the statements and particulars given on this form are true to the best of my/our knowledge and belief and that I/we have not suppressed, withheld or modified any material facts. I/we agree that should a policy be issued, this form shall be the basis of the contract, and that any changes in the pattern of my/our trade or trade practices shall be advised to the Underwriters who may, at their discretion, vary the terms and conditions of the contract.

Date (dd/mm/yyyy)

Signature of Insured

Title/Position