Operations

Questions 1–9 — describe your operations.

1. Number of years in business *

2. Description of operations *

3. Breakout of operations:

a. New Utility Line Construction (%)

b. Utility Line Servicing or Repair (%)

4. Does the insured perform any work in metropolitan areas?

Yes No

5. Does the insured perform residential work?

Yes No

6. Type of Utility Line (select all that apply, with % of total operations)

a. % transmission lines

b. % distribution lines

7. Is the applicant licensed?

Yes No

8. States performing work *

9. Annual employee turnover (%) *

Are you connecting utilities to residential properties?

Yes No

Are you connecting utilities to commercial buildings?

Yes No

Do you work inside buildings?

Yes No

Indoor / outdoor work split:

% work inside buildings

% work outside buildings

Percentage of current operations:

General Contractor (%)

Subcontractor (%)

Construction Manager (%)

A. New York State applicants — Any work in the five boroughs of New York?

Yes No

B. All applicants — Do you perform any work in Colorado?

Yes No

Underground Operations

Questions 10–15 — underground exposure.

Not applicable — applicant performs no underground operations

Overhead Operations

Questions 16–19 — overhead exposure.

Not applicable — applicant performs no overhead operations

16. Breakout of operations:

a. Distribution Powerlines (%)

b. Transmission Powerlines (%)

c. Erection of Poles or Towers (%)

17. Average height of powerline work (ft)

18. Maximum height of powerline (ft)

19. Is the insured contracted to perform Tree Trimming?

Yes No

Loss Control & Prevention

Questions 20–26 — safety, contracting, and training.

20. Does the insured have a safety program?

Yes No

21. Elaborate on Site-Specific Safety Assessments and Procedures

22. Person assigned to maintain and implement safety procedures:

a. Name

b. Title

23. Does the insured have a safety supervisor at every site?

Yes No

24. How are servicing operations contracted?

a. Master Service Agreements (%)

% with hold harmless in applicant's favor

% with hold harmless in client's favor

% with mutual hold harmless

b. Individual Job Order / Purchase Order (%)

25. Years of relevant industry experience required for new hires

26. Elaborate on new-hire training procedures

Subcontractors & Signature

Final section — subcontractor information and applicant signature.

1. Describe any work performed by subcontractors

2. Certificate of Insurance:

a. Does the insured obtain and have on file?

Yes No

b. Is the applicant added as additional insured on subcontractor policies?

Yes No

c. Minimum General Liability and Pollution Liability limits required

3. Are indemnification and hold harmless agreements received from all subcontractors?

Yes No

Signature & Agreement

The applicant agrees, represents, and warrants that the statements and information contained in this application for insurance, including all statements, information, and documents accompanying or relating to this application, are accurate and complete and no facts have been suppressed, omitted, or misstated. Any failure to fully disclose the information requested, whether by omission or suppression, or any misrepresentation in the statements and information contained in this application, renders coverage for any claim(s) null and void and entitles the insurer to rescind the policy from its inception.

Applicant's Signature (full legal name) *

Title of Applicant *

Date *

	Estimated	Current Year	Previous Year
Gross Receipts ($)
Field Payroll ($)
Office Payroll ($)
Sub-costs ($)
# of Employees

Utility Contractors Supplemental

General Information

Historical Exposures

Operations

Underground Operations

Overhead Operations

Loss Control & Prevention

Subcontractors & Signature

Signature & Agreement

Application Submitted!