Please note: All fields in this form are required.
     Applicant Information

NAMED INSURED:
STREET:
CITY:
STATE:
ZIP:
COUNTRY:
PHONE:
FAX:
EMAIL:
 

XXXLocation of Operations

 
STREET:
CITY:
STATE:
ZIP:
COUNTRY:
 

   APPLICANT IS A (AN)
INDIVIDUALParall PARTNERSHIP Paralo CORPORATION Paralo OTHER
 

   GENERALLY DESCRIBE THE TYPE OF INDUSTRY SERVICED BY THE TRACK OPERATOR.
    (FAX OR MAIL A SYSTEMS MAP FOR YOUR LINE IF AVAILABLE)
 
 

   LIST ALL TRACK OPERATORS AND ADDITIONAL INSUREDS TO BE NAMED WITH A BRIEF EXPLANATION
   AS TO THEIR INTEREST (FAX OR MAIL CONTRACTUAL AGREEMENT)
 
 
   WHAT LIMITS ARE REQUIRED OF TRACK OPERATORS?
$
 
      Requested Program:
 
REQUESTED LIMIT: $
 
SIR: $
 
PROPOSED EFFECTIVE DATE: (mm/dd/yyyy)
 
     Current Program:
 
INSURER(S):
SELF-INSURED RETENTION:
LIMITS CARRIED : $
PREMIUM & RATE (INDICATE RATING BASIS): $
TERM:  (years)
RETRO OR
FIRST COVERAGE DATE:		  (mm/dd/yyyy)
 
   TOTAL MILES OF OWNED TRACK INCLUDING YARD TRACK:
 
MILES BY CLASSIFICATION: ACCEPTED: FRA-1: FRA-2: FRA-3 OR BETTER:  
 MAIN LINE:
 BRANCH LINE:
YARD TRACK:
 
   TRAFFIC OVER LINE:  
No. TRAINS PER WEEK:
AVERAGE CARS PER TRAIN:
AVERAGE SPEED PER TRAIN:
MAXIMUM SPEED OF TRAIN:
 
   GRADE CROSSINGS: PUBLIC PRIVATE  
No. PROTECTED BY LIGHTS AND OR GATES:  
No. PROTECTED BY
CROSS BUCKS: 		 
No. UNPROTECTED:  
 
   WHO IS RESPONSIBLE FOR NORMAL RIGHT-A-WAY MAINTENANCE FOR THE LAST TWO (2) YEARS?
NAME:
 
   ESTIMATE FOR NORMAL RIGHT-A-WAY MAINTENANCE FOR EACH OF THE LAST TWO (2) YEARS
   AND AN ESTIMATE FOR THE COMING YEAR (NOT INCLUDING SUBSIDIES/GRANTS:
YEAR: PREVIOUS: CURRENT:      
$ $      
$ $      
 
YEAR: PROJECTED:        
$        
 
   BRIEFLY DESCRIBE ANY REHAB WORK CURRENTLY BEING DONE OR PLANNED FOR THE
   COMING YEAR (FAX OR SEND M/W PLAN IF AVAILABLE):
 
   LIST MAJOR COMMODITIES HANDLED OVER TRACK DURING PAST YEAR AND INDICATE
   IF ANY ARE HAZARDOUS MATERIALS, CHEMICALS, EXPLOSIVES WITH % OF EACH:
  COMMODITY % HAZARDOUS
YES    NO
YES    NO
YES    NO
YES    NO
YES    NO
YES    NO
TOTAL 100%  
 
     Loss Experience:
 
   LIST ALL TRACK OPERATORS AND ADDITIONAL INSUREDS TO BE NAMED WITH A BRIEF EXPLANATION
   AS TO THEIR INTEREST (FAX OR MAIL CONTRACTUAL AGREEMENT)
Complete dates as follows (mm/dd/yyyy)
PROPOSED EFFECTIVE DATE: TYPE OF LOSS: NUMBER OF CLAIMS: TOTAL PAID: TOTAL INCURRED: VALUATION DATE:
 
   LIST AND DESCRIBE ANY CLAIM PAID OR RESERVED OVER THE LAST FIVE (5) YEARS IN EXCESS OF 10,000:
  MUST SELECT ONE: NONE    WILL EXPLAIN BELOW
Complete dates as follows (mm/dd/yyyy)
DATE: TYPE OF LOSS: AMOUNT: COMMENT:
 
      Contact information in the event of a Loss Control Survey
 
CONTACT NAME:
PHONE:
 
      Agent or Broker Information
 
CONTACT NAME:
COMPANY NAME:
STREET:
CITY:
STATE:
ZIP:
COUNTRY:
PHONE NUMBER:
EMAIL ADDRESS:


We acknowledge that we have received and read a specimen copy of the policy for which we are applying. We understand that the insurance afforded by this policy is on a claims made basis.

We know of no other relevant facts which might affect the company's judgement when considering this application and herby agree that any answers given in this application shall not constitute notice of circumstances or notice of claim as provided for in the insuring agreements or conditions of any policy issued by the company to the applicant, prior to the inception date of the policy to which this application applies.

Should the company decide to issue any insurance following the submission of this proposal, then this proposal and any supplementary information pertaining hereto shall form the basis of any policy issued and be deemed incorporated therein.

The named insured on behalf of all proposed insured(s) warrants it has the authority to so a CT and that upon its inquiry all statements herein are true and correct to the base of its knowledge and that no material facts have been suppressed or misstated.
Submitted and dated at (time) This Day of ,
  Submitted on behalf of the proposed insured(s) by:
 

  Relationship. Official title and/or position with the proposed named insured of the person who completed and signed this application:

 
 
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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