Application Form HYDROELECTRIC APPLICATION SUPPLEMENT LIABILITY Step 1 of 9 - PROJECT INFORMATION 11% Insured Name: First Last Mailing Address I. PROJECT INFORMATIONNamed insured is: Owner/Operator Contract operator Owner/Developer General contractor Other (check all that apply) Project Name: Exact Site Location: Inspection Contact Name & Number Is the facility run of river? impoundment? diversion? pump storage? Annual production: (KWH) Rated capacity: (MW) Annual power sales: $ Project is: Urban Rural Remote Is the project operated/maintained by you? others? Is the project manned? unmanned? If unmannedFrequency of visits is Daily weekly monthly Is there automatic notification to supervisor in the event of emergency? yes no Travel time from remote monitor to site: Does the project include a dam diversion (Submit a dam safety inspection report if available.)Is it owned? leased? who is the owner? Type of dam: concrete gravity timber crib arch embankment buttress Size:lengthheightwidthYear built Reservoir capacity (acre-feet): Are flashboards used? Yes No Are they mechanical wooden What is the head distance: Detail the spill ways or overflow facilities in place:Provide lead times of critical equipment in the event of failure (i.e. turbines):Check if applicable protective devices for this project. Over speed trip Low lube oil High vibration Wicket gate protection Ground fault trip Reverse current Over current trip Loss of excitation Lightning protection Please attach a copy of the most recent FERC report (if applicable)Max. file size: 300 MB.Please attach a 5-year loss history (if applicable)Max. file size: 300 MB. II. GENERAL LIABILITY COVERAGE INFORMATIONIf you are requesting General Liability Coverage, please complete this section.Limit of Indemnity $1,000,000 $2,000,000 $5,000,000 Effective Date: Is the site secured with fences, locked gates or other physical barriers? Yes No Are there hazard warning signs at the premises? Yes No Is the public allowed access to the premises? Yes No Are there any recreational facilities on or adjacent to your premises? Yes No Are there any dams, reservoirs, or other hydroelectric facilities upstream that can affect your operation? Yes No Describe:What structures, (mobile homes, residential areas or commercial areas), are downstream of the plant? How far are they away from the plant? Are the banks of the river tall enough down stream to contain all of the water in case of a total water containment failure? Does the plant use a dam or diversion? If the plant has a dam, is it high, medium or low hazard? If the plant has a high hazard dam, does the plant have an emergency plan on file with FERC? Is the dam or diversion in an urban or rural location?Do you have a written emergency action plan? Yes No When? III. PROPERTY COVERAGE INFORMATIONIf you are requesting Property Coverage, please complete this section.A. PowerhouseYear Built: Has the powerhouse been refurbished? Yes No When? Is there remote monitoring? Yes No Details of the site security:History of flooding of buildings, structures, equipment on site:Flood Zone: Build above the 100 year Flood Plain? Yes No B. Turbine(s)Turbine 1Type Pelton Kaplan Francis Bulb Year Built: Rebuilt: Yes No Date Rebuilt: MM slash DD slash YYYY by Whom: Turbine 2Type Pelton Kaplan Francis Bulb Year Built: Rebuilt: Yes No Date Rebuilt: MM slash DD slash YYYY by Whom: Turbine 3Type Pelton Kaplan Francis Bulb Year Built: Rebuilt: Yes No Date Rebuilt: MM slash DD slash YYYY by Whom: Spares kept on site: Generator(s)Generator 1Size Type Synchronous Induction Year Built: Rebuilt Yes No Date MM slash DD slash YYYY by Whom: Generator 2Size Type Synchronous Induction Year Built: Rebuilt Yes No Date MM slash DD slash YYYY by Whom: Generator 3Size Type Synchronous Induction Year Built: Rebuilt Yes No Date MM slash DD slash YYYY by Whom: Transmission and DistributionTransformer 1Size: Transformer 2Size: Transformer 3Size: Do you own transmission lines? Yes No How long is it? Is substation on site and owned by project? Yes No Dam and DiversionIs the dam or diversion structure to be insured? Yes No Please state values:Dam ($) Diversion ($) If the dam or diversion is leased, what is the replacement cost of improvements and betterments? $ F. PenstockIs the penstock to be insured? Yes No Values ($): Type: Steel Concrete Is the penstock above ground underground G. Property LimitsPlease attach a statement of values worksheetMax. file size: 300 MB. Declaration and SignatureThe undersigned declares that to the best of his or her knowledge and belief the statements and in formation in this application statement are true. The company is hereby authorized to make any investigation and inquiry in connection with the application statement that it deems necessary.Dated: MM slash DD slash YYYY Signed (First Named Insured)Title Submitted by: (Producer)Date MM slash DD slash YYYY FALSE INFORMATION ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER 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.CAPTCHAfifteen x 1 = ? NameThis field is for validation purposes and should be left unchanged. Δ
