Application Form EIB Biomass Application EIB Biomass Application Step 1 of 9 - PROJECT INFORMATION 11% Insured Name: First Last Website Years in BusinessYears of ExperienceExperience in field I. PROJECT INFORMATIONNamed insured is: Owner/Operator Contract operator Owner/Developer General contractor Other (check all that apply) Project Name: Location: 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? Frequency of visits is daily weekly monthly Is there automatic notification to supervisor in the event of emergency? yes no II. EQUIPMENT / CONTRACTOR INFORMATIONAny equipment rental? Yes No What percent of work is subcontracted out?Are subcontractors always insured? Yes No Are you named as an additional insured on all subcontractors’ policies? Yes No Do you have a written contract with your subcontractors? Yes No III. GENERAL LIABILITY COVERAGE INFORMATIONIf you are requesting Property Coverage, please complete this section.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 Do you have a written emergency action plan? Yes No III. PROPERTY COVERAGE INFORMATIONIf you are requesting Property Coverage, please complete this section.A. PowerhouseYear Built: Has the powerhouse been refurbished? Yes No When? Was the powerhouse designed above the 100 year flood plain? Yes No B. Turbine(s)Turbine 1Type Pelton Kaplan Francis Bulb RPM: Year Built: Rebuilt: Yes No Date Rebuilt: MM slash DD slash YYYY by Whom: Turbine 2Type Pelton Kaplan Francis Bulb RPM: Year Built: Rebuilt: Yes No Date Rebuilt: MM slash DD slash YYYY by Whom: Turbine 3Type Pelton Kaplan Francis Bulb RPM: Year Built: Rebuilt: Yes No Date Rebuilt: MM slash DD slash YYYY by Whom: Generator(s)Generator 1Size Type Synchronous Induction Year Built: Rebuilt Yes No Date MM slash DD slash YYYY by Whom: RPM: Generator 2Type Synchronous Induction Size Year Built: Rebuilt Yes No Date MM slash DD slash YYYY by Whom: RPM: Generator 3Type Synchronous Induction Size Year Built: Rebuilt Yes No Date MM slash DD slash YYYY by Whom: RPM: Transmission and DistributionTransformer 1Size: Do you own transmission lines?* Yes No If yes, how long is it?* Transformer 2Size: Do you own transmission lines?* Yes No If yes, how long is it?* Transformer 3Size: Do you own transmission lines?* Yes No If yes, how long is it?* Do you own transmission lines? Yes No How long is it? Declaration and SignatureThe undersigned declares that to the best of his or her knowledge and belief the statements and information 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 Email address Phone NumberCell Phone NumberMailing address (First Named Insured) 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.CAPTCHA45 - five = ? NameThis field is for validation purposes and should be left unchanged. Δ
