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 ProductionInsurance.com

  A Service of Supple-Merrill & Driscoll, Inc.

 

  

 

 Railroad Protective Liability Insurance Application Instructions

  1. Please complete and submit this online application for a free, no-obligation quote.

  2. Please be sure to provide all required information in order to receive a quotation. 

 

  Program Information

This is a secure application.  Strong cryptography is implemented via the Secure Sockets Layer protocol.  Our Privacy Policy.

  PDF Application (Fillable)

 

( indicates required information)

Applicant (Contractor/Production) Information

Name of Company / Organization:
Entity:  
Full Name of Contact:
Number:
Fax:
Street Address:
City, State: ,
Zip/Postal Code:

Email:

We will never rent, sell, or share your email address.

Applicant Type:

Insured (Railroad) Information

Insured / Railroad Information:
Street Address:
City, State: ,  

Province:

If Canada

Zip/Postal Code:

Project Information

Estimated Duration of Project:
Proposed Effective Date:

Proposed Expiration Date:

End of the contract term, up to 2 years.

Work Performed For:

Railroad  Government Authority/Other

Name (work being performed for) and address if Government Authority / Other

Does the project involve only overhead lines and/or wire work?:

Yes  No

If other types of construction are involved, then answer "No".

Does the project involve only underground lines/wire and/or

underground pipe work?

Yes  No

If other types of construction are involved, then answer "No".

Description of Work to be Performed:

Including location/proximity to railroad tracks.

Description of Work to be Performed Within 50 Feet of Tracks:

Not Applicable

Including Designated Contractor's Specific Work.

Contract Number or Name:

Project Location:

City:    

State:  

Be as detailed as possible - mile marker, cross road, etc.

Where is the Work in Relation to the Railroad Tracks:

Adjacent To The Tracks
Over The Tracks
Under The Tracks
At Right Angles To The Tracks
Parallel To The Tracks
Being Performed Within 50 Feet of Tracks

        Check All That Apply

Does the Project or Named Insured's Operations Involve Any of the Following?

Use of explosives or fireworks

Underground construction such as subways or mines

        Does not apply to underground pipe.

Work in refineries, chemical plants, mills, or grain elevators
Hazardous chemicals
Underwater
Erecting a new building over 3 stories within 50 feet of the tracks
Actual construction of tracks while any trains pass through the right of way

        Check All That Apply

Total Contract Price:
Contract Price Within 50 Feet of the Tracks:
Number of Trains Per Day:
Requested Policy Limits

Requested Policy Limits:

Contractor/Production Information
Primary Insurance Carriers:

Limits:

Carrier:   Policy #

Effective Date:

Excess Insurance Carrier:

Limits:

    If other:

Carrier:   Policy #

Effective Date:

Will a project contract, including a hold harmless agreement, be

assigned by the designated contractor?

Yes  No

Will the railroad be named as an additional insured on

 the contractor’s GL policy?

Yes  No

Will the contractual exclusion for the work within 50 feet of the railroad property be deleted on the contractor’s general liability and umbrella policies?

Yes  No
Is a Slow Order in place for the duration of the project? Yes  No
Will the railroad assign flagmen or supervisors to the project? Yes  No
Will other railroad employees (other than flagmen/supervisors)

be assigned to the project?

Yes  No

Notes

 

 

 

Terms and Conditions

Please carefully review the Terms and Conditions below:

  • Please read all exclusions indicated on quotation.

  • The quotation received is not binding on the Insurer in any way.

  • By clicking 'Submit Application' you are not agreeing to purchase coverage.  Via email, you will receive a free, no-obligation insurance quotation.

  • Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and (NY: substantial) civil penalties. (Not applicable in CO, HI, NE, OH, OK, OR, VT). In DC, LA, ME, TN and VA, insurance benefits may also be denied.
  • Please note that once coverage is bound, the policy cannot be cancelled.

  • The insurance quotation will be based solely on the coverages and limits selected on this application.

  • The carrier reserves the right to refuse any binder for ineligible exposures including but not limited to any erroneous, incomplete, or inaccurate applications.

  • Please ask your Supple-Merrill & Driscoll, Inc. representative to explain coverage details, exclusions, limits or other provisions of any insurance policy.

Type your name below, to indicate that you have read

and accepted the Terms and Conditions above:

 

 

 

  

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