Please note: All fields in this form are required.
 

The completion and submission to the company of this application does not constitute a binder of insurance nor any insurance whatsoever nor does the company undertake to offer any terms for coverage.

Only railroad equipment which is submitted to and on file with the company is insured. The applicant should take great care to make certain that information for all railroad equipment for which insurance is desired is submitted with this application.

The Contingent Railroad Equipment Liability Policy does not grant automatic coverage for newly acquired railroad equipment. Any equipment so acquired should be submitted to the company prior to the date coverage is desired
XXXI.   Applicant Information
 

NAMED INSURED:
STREET:
CITY:
STATE:
ZIP:
COUNTRY:
 
     TYPE OF BUSINESS OPERATION:
 
     ADDITIONAL INSUREDS TO BE NAMED AND WHY:
 
PROPOSED EFFECTIVE DATE: (mm/dd/yyyy)
 
    HAVE YOU INSURED THIS RAILROAD EQUIPMENT FOR CONTINGENT LIABILITY BEFORE?
    Yes                 No
 

INSURER NAME:
NUMBER:
 
CLAIMS MADE : YesParalle                  No Paral  $ Limits
IF YES, HOW WERE THEY PAID? : DeductibleParalle   l t Self-Insured Parall None
 

AMOUNT:

          $ 

POLICY PERIOD:

  FROM:        TO: (mm/dd/yyyy)

RETROACTIVE DATE :

              (mm/dd/yyyy)

PREMIUM & RATES:

              RATES:
 
 
    HAS ANY INSURER EVER DECLINED TO INSURE, CANCELLED OR NON-RENEWED YOUR CONTINGENT RAILROAD
    EQUIPMENT LIABILITY INSURANCE?
  o Yes                 No
 
    IF YES, PLEASE EXPLAIN:
 
NO. OF YEARS IN
RAILCAR BUSINESS:		      (Please provide resumes of key personnel if you have been in the
Railcar Repair Business less than (3) years.)
 
 

XXXII.  Please attach a complete schedule of all railroad equipment to be insured.
             Include type of equipment and reporting marks.
 
    DO YOU HAVE ANY NON-OWNED RAILROAD EQUIPMENT THAT YOU HAVE ASSUMED RESPONSIBILITY FOR INSURING?
o Yes                 No
 
    IF YES, IS IT INCLUDED IN THE SCHEDULE SPECIFIED IN SCHEDULE ABOVE?
o Yes                 No
    IF YES, INDICATE WHICH EQUIPMENT, WHO OWNS IT AND THE EXTENT OF OUR RESPONSIBILITY
    (IF UNDER A WRITTEN CONTRACT OR AGREEMENT, FAX TO 410.515.0154, ATTN: JOE SCHEIDE)
    IF NO, FAX A COMPLETE SCHEDULE AS PER SCHEDULE ABOVE TO 410.515.0154, ATTN: JOE SCHEIDE.
 
    DO YOU PLAN ANY FUTURE PURCHASES OR OTHER ACQUISITIONS OF RAILROAD EQUIPMENT?
o Yes                 No
 
    IF YES, PLEASE DESCRIBE:
 
    DO YOU MANAGE THIS EQUIPMENT FOR OTHERS AND / OR LEASE THIS EQUIPMENT TO OTHERS?
o Yes                 No
    IF YES, FAX TO 410.515.0154, ATTN: JOE SCHEIDE A COMPLETE SCHEDULE OF ALL LESSEES OR RAILROAD
    EQUIPMENT FOR WHICH YOU DESIRE INSURANCE COVERAGE. FAX COMPLETE COPIES OF ALL MANAGEMENT
    AND OR LEASE AGREEMENTS AND CONTRACTS.
 
    WHAT IS THE LEAST AMOUNT OF LIABILITY INSURANCE THAT YOU WILL ALLOW A LESSEE TO MAINTAIN?

$

 
    IS THIS RAILROAD EQUIPMENT USED TO TRANSPORT YOUR OWN COMMODITIES?
o Yes                 No
 
    IF YES, DOES YOUR GENERAL LIABILITY CARRIER COVER THIS EQUIPMENT WHILE IT IS ON YOUR PRIMISES?
o Yes                 No
 
    IF YES, PLEASE PROVIDE:

CARRIER:

TERM:

LIMITS:
 
    LIST THE RAILROAD(S) THAT SERVICE YOU:
 
    IS THIS EQUIPMENT STORED AT YOUR PREMISES WHEN NOT IN USE?
o Yes                 No
 
    WIF NO, WHO IS RESPONSIBLE FOR LIABILITY?
NAME:
 
    WHAT PERCENTAGE OF THE TIME IS THE EQUIPMENT IN YOUR CARE, CUSTODY AND CONTROL?
%
 
    LIST THE TYPES OF COMMODITIES HAULED IN YOUR RAILROAD EQUIPMENT:
 
    IS ANY OF YOUR RAILROAD EQUIPMENT USED TO CARRY HAZARDOUS MATERIAL?
o Yes                 No
 
    IF YES, LIST THE TYPE(S)OF HAZARDOUS MATERIALS AND NUMBER OF TYPES OF CARS INVOLVED:
 
    ARE YOU RESPONSIBLE FOR THE MAINTENANCE AND REPAIR OF YOUR RAILROAD EQUIPMENT?
o Yes                 No
 
    IF YES, AND YOU DO YOUR OWN WORK, PLEASE DESCRIBE YOUR FACILITES
    AND THE QUALIFICATIONS OF YOUR PERSONNEL:
 
    IF YES, AND YOU SUBCONTRACT THE WORK TO OTHERS, IS IT AN A.A.R. APPROVED REPAIR SHOP?
o Yes                 No
 
    IF YOU ARE NOT RESPONSIBLE FOR THE MAINTENANCE AND REPAIR OF YOUR RAILROAD EQUIPMENT,
    ARE YOU INDEMNIFIED AND HELD HARMLESS BY THE PARTY THAT IS RESPONSIBLE?
    (IF YES, FAX A COMPLETE AGREEMENT TO 410.515.0154, ATTN: JOE SCHEIDE)
o Yes                 No          
 
    DO YOU OBTAIN CERTIFICATES OF INSURANCE?
o Yes                 No
 
     DESCRIBE ANY LOSSES THAT AROSE OUT OF YOUR RAILROAD EQUIPMENT.
 

XXXIII.  Other Information

 
 
XXXIV.  Agent or Broker Information
 
CONTACT NAME:
COMPANY NAME:
STREET:
CITY:
STATE:
ZIP:
COUNTRY:
PHONE NUMBER:
EMAIL ADDRESS:
 
Submit Form:  
Reset Form:  

For questions or information about the railroad protective online form call:

Joe Scheide, Director of Marketing

p. 410.515.1190 or 800.223.8098
f. 410.515.0154

or email: jscheide@cantonagency.com