* Indicates required fields.
XXXApplicant Information
 

*PROPOSED FIRST
NAMED INSURED:
*STREET:
*CITY:
*STATE:
*ZIP:
*COUNTRY:
 
PROPOSED ADDITIONAL INSURERS:
 

XXXRevenue and Payroll Information

 
*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.)
*NO. OF YEARS
IN SPECIFIFIED SPECIALITY:
*NO. OF EMPLOYEES:
*PROJECTED ANNUAL RAILCAR REVENUE:
*PROJECTED TOTAL OPERATING REVENUE:
*CURRENT YEAR ANNUAL RAILCAR REVENUE:
*CURRENT YEAR TOTAL OPERATING REVENUE:
*PRIOR YEAR ANNUAL RAILCAR REVENUE:
*PRIOR YEAR TOTAL OPERATING REVENUE:
*CURRENT RAILCAR REPAIR PAYROLL:
*PROJECTED RAILCAR REPAIR PAYROLL:
*PROJECTED TOTAL PAYROLL:
 

XXXLocomotive Repair

 
*MAINTENANCE: %
*REBUILD, OVERHAUL: %
*ELECTRICAL,
COMMNICATION SYSTEMS,
COMPUTER SYSTEMS:		 %
*PAINTING,WELDING,
BODY REPAIR:		 %
*SUSPENSION SYSTEMS: %
*WHEELS,
BRAKES, OTHERS		 %
TOTAL:  100%
 
XXXRailcar Repair
 
*CLEANING: %
*INSPECTION: %
*ROUTINE
MAINTENANCE:		 %
*WHEELS, BRAKES,
SUSPENSION WORK:		 %
*WRECK REPAIR: %
*PAINTING, WELDING,
BODY REPAIR:		 %
TOTAL:  100%
 

XXXTank Car Repair

 
*PRESSURIZED TANK TESTING: %
WHEELS, BRAKES,
SUSPENSION WORK:		 %
INSPECTION,
CERTIFICATION: 		%
TANK RELINING: %
 
*NON
PRESSURIZED		 PAINTING, WELDING,
BODY REPAIR:		 %
CLEANING: %
OTHER: %
TOTAL:  100%
 
*OTHER
PASSENGER CARS,
CONTRACTORS
EQUIPTMENT, ETC.
DESCRIBE "OTHER"
IN DETAIL:
 
*LIST NAMES OF
CURRENT MAJOR
CUSTOMERS:
 
*LIST CUSTOMERS
NAMES FROM
PREVIOUS YEAR:
 

XXXPremises

 
*AGE OF BUILDING:
 
*CONSTRUCTION:  Frame              Steel Parallel to Masonry Parallel to Stone
 
*UL APPROVED
PAINTING AREA:		 Yes                 No
 
*ARE FLAMMABLE,
HAZARDOUS
MATERIALS
PROPERLY STORED:		 Yes                 No

 
*DOES BUILDING
HAVE AUTOMATIC
SPRINKLER / FIRE
SUPRESSION SYSTEMS:		 Yes                 No
 
*IF YES, CHECK
TYPE OF SYSTEM:		 Dry PipeParall Wet Pipe Paralo Halon
 
*DO YOU HAVE AN
APPROVED WASTE
DISPOSAL
CONTRACTOR:		 Yes                 No
 

XXXOperations
 
*AAR
CERTIFIED SHOP:		 Yes                 No
 
*WHAT TYPE
OF WORK IS
SUBCONTRACTED:
*ARE CERTIFICATES
OF INSURANCE
OBTAINED FROM ALL
SUBCONTRACTORS:		 Yes                 No
 
*WHAT LIMITS OF
LIABILITY ARE
REQUIRED FROM
SUBCONTRACTORS:		 $
 
*DOES
APPLICANT
(proposed insured)
REQUIRE TO
HOLD HARMLESS
AGREEMENST FROM
SUBCONTRACTORS:		 Yes                 No
 
*WHAT PERCENT OF
WORK IS DONE
OFF PREMISES:		 %
 
*TYPE OF WORK
DONE OFF PREMISES:
 
*RADIUS OF OFF
PREMISE WORK:
 
DESCRIBE
ENGINEERING OR
DESIGN WORK
IF ANY:
 
*DO YOU UTILIZE
A WRITTEN WORK
ORDER
(if YES, provide copy):		 Yes                 No
 
*IS THERE A FORMAL
WRITTEN SAFETY
PROGRAM
(if YES, provide copy):		 Yes                 No
 
XXXAttachments Required - Fax to 410.515.0154, Att: Joe Scheide
 
    •  5 years of hard copy loss runs
    •  Copy of Standard Contract used
    •  Company brochure
    •  Copy of Safety Program / Quality Control Program
 
XXXAdditional Comments
 
 
XXXAgent 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