Loggers Broad Form Insurance | Loggers Broad Form

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APPLICANT INFORMATION
LOGGERS THIRD PARTY PROPERTY DAMGAGE LIABILITY POLICY APPLICATION

Note: At the end of this form there is an “upload” button which will allow you to upload .pdf files. Feel free to submit your current/expiring policy, loss runs and any hold harmless agreement you hold. If you need assistance in completing this form call 209 223-1870.
Contact Information
Name of person completing this form*
Phone*
Email*

Enter Email

Confirm Email
Applicants Information
Name of Company*
Entity type*
Name of owner or first named insured if different from company name*
LTO license number / Timber License
Contractor’s License Number
Physical address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country
Is the physical address the same as the “mail address?”*
Mailing address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country
Website
Phone*
Cell Phone
Fax number
Email*
Number of employees*
Number of years in business*
Briefly describe your experience*
Coverage Required
What is your desired effective date if approved?*

DD slash MM slash YYYY
Limits*
Deductible*
Payroll “estimates” for the next 12 months in the following
1. Logging on your lands*
1. Payroll*
2. Logging by owner*
2. Payroll*
3. Logging by employees*
3. Payroll*
4. Log Road Building*
4. Payroll*
5. Subcontract Logging*
5. Payroll*
6. Subcontract Log Hauling*
6. Payroll*
7. Truck Drivers*
7. Payroll*
8. Other describe*
8. Payroll*
Please provide percentage Owner/Officers/Partners are active at job site

Logging Operations
List areas of operation: (States, Counties, Towns & Regions)
Do you own the land upon which you or others are operating?*
- Yes
- No
If “NO”, are all required permits in place with appropriate authorities?*
- Yes
- No
Is there a signed contract with the owner?*
- Yes
- No
Please provide a description of your logging operations*
What precautions do you take to prevent trespassing onto others Land?*
What methods do you use to determine boundaries and identify trees for cutting?*

Activities: Please check all that apply

The total of all check boxes in this section should total 100%. If there is no activity please insert “0” (zero)
1. Felling*
- Yes
- No
1. % of Payroll*
2. Tree Trimming*
- Yes
- No
2. % Payroll*
3. Log Road Building*
- Yes
- No
3. % Payroll*
4. Skidding*
- Yes
- No
4. % Payroll*
5. Excavation*
- Yes
- No
5. % Payroll*
6. Blasting/Use of Explosives*
- Yes
- No
6. % Payroll*
7. Work in Residential Areas*
- Yes
- No
7. % Payroll*
7. What percentage of logging payroll is derived from residential payroll? Please state the nature of the work and all the Loss Prevention measures take to prevent loss.
8. Slash Burning*
- Yes
- No
8. % Payroll*
8a. Cont. Slash burning: What controls and safeguards are applied to prevent unintended spread of fire?
8b. Slash burning: Do you only burn at times or under conditions approved by proper state or federal authorities?
- Yes
- No
9. Sawmill Operations (including portable)*
- Yes
- No
9. % Payroll
10. Woodworking*
- Yes
- No
10. % Payroll*
11a. Manufacturing cont. : Please state the nature of operations
11. Manufacturing*
- Yes
- No
11. % Payroll*
12. Use of Aircraft, Helicopter or Watercraft*
- Yes
- No
12. % Payroll*
13. Work for Utility Companies*
- Yes
- No
13. % Payroll*
14. Work close to Power Lines*
- Yes
- No
14. % Payroll*
15. Construction of Bridges, Tunnerls or Dams*
- Yes
- No
15. % Payroll*
16. Other type of work*
- Yes
- No
16. % Payroll*
16. Describe other kind of work.
Additional Insured
How many additional insured do you anticipate you will need in the next 12 month?*
Are any of the Additional Insured a Utility Company?
- Yes
- No
Underwriting continued
Do you subcontract any of your logging and ancillary work or operations to any third parties?*
- Yes
- No
Do all subcontractors provide evidence of insurance equal to or greater than your liability limtis?
- Yes
- No
Are you named as “Additional Insured” on Subcontractors policies?
- Yes
- No
Have you sustained any losses, insured or uninsured, which would have been covered under this form of insurance had you carried such policy?*
- Yes
- No
Please explain details of such loss included date, location and how the loss occured
Have there been any fires or Claims for fires occurring in the last 10 years on the land while you were working on that land?*
- Yes
- No
Please explain fires, dates and locations
Please provide details including date and location
- Yes
- No
Have you ever had a liability insurance policy cancelled, declined, non-renewed or has any carrier posed any special terms?*
- Yes
- No
Do you have Commercial General Liability?
- Yes
- No
Commercial General liability is required along with LBF.

We can provide a quot on Logger Broad Form but note. The carrier will required proof of “General Liability” in order to issue / keep the Loggers Broad Form Policy.
What are the General Liability current limits?
What is the name of your current insurance carrier?
What is the current policy term? (start date & expiration date)
Do you require coverage for Oregon Fire Suppression Costs?*
- Yes
- No
Do you hold any hold harmless agreements?*
- Yes
- No
Please explain the circumstances and provide copies.

You can either upload them here, fax, email or mail the hold harmless agreements. Our fax number is 209 223-3227, email to insurance@athenainsurance.com or Athena Insurance P.O. Box 390, Pine Grove CA 95665.
File Upload of existing documents
Drop files here or

Accepted file types: jeg, pdf, Max. file size: 7 MB, Max. files: 9.
Please use this area to upload such items such as loss runs, current/expiring policy and hold harmless agreement. Multiple file upload is allowed.
Terms of Service
- I agree to the Terms of Service

APPLICANT INFORMATION

LOGGERS THIRD PARTY PROPERTY DAMGAGE LIABILITY POLICY APPLICATION

Note: At the end of this form there is an "upload" button which will allow you to upload .pdf files. Feel free to submit your current/expiring policy, loss runs and any hold harmless agreement you hold. If you need assistance in completing this form call 209 223-1870.

Underwriters will rely upon each and every response given in this application and any supplemental application or questions in deciding whether or not to insure you. And if so, at what premium, terms and conditions. Underwriters regard every response to be material to their decisions. Failing to answer or answering any question below incorrectly could invalidate any policy of insurance written by underwriters for your business.

Contact Information

Name of person completing this form(Required)

Phone(Required)

Email(Required)

Enter Email Confirm Email

Applicants Information

Name of Company

Entity type

Name of owner or first named insured if different from company name(Required)

For example, the company name is xyz, inc. and the owner is name Steve Valencia. Steve Valencia would be the first named insured. Although there are other officers in a corporation only one can be named as first named insured and they alone are the only person to which all legal notices are directed.

LTO license number / Timber License

Contractor's License Number

Physical address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Is the physical address the same as the "mail address?"(Required)

Mailing address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Cell Phone

Fax number

Number of employees(Required)

Number of years in business(Required)

Briefly describe your experience(Required)

Coverage Required

What is your desired effective date if approved?(Required)

DD slash MM slash YYYY

Limits(Required)

Deductible(Required)

Payroll "estimates" for the next 12 months in the following

1. Logging on your lands

1. Payroll

2. Logging by owner

2. Payroll

3. Logging by employees

If none type none

3. Payroll

If none type none

4. Log Road Building

If none type none

4. Payroll

If none type none

5. Subcontract Logging

If none type none

5. Payroll

If none type none

6. Subcontract Log Hauling

If none type none

6. Payroll

If none type none

7. Truck Drivers

If none type none

7. Payroll

If none type none

8. Other describe

If none type none

8. Payroll

If none type none

Please provide percentage Owner/Officers/Partners are active at job site

Logging Operations

List areas of operation: (States, Counties, Towns & Regions)

List all areas project to work in over the next twelve months

Do you own the land upon which you or others are operating?

Yes

If "NO", are all required permits in place with appropriate authorities?

Yes

Is there a signed contract with the owner?

Yes

Please provide a description of your logging operations(Required)

What precautions do you take to prevent trespassing onto others Land?(Required)

For example do you require it be surveys and marked. Are foresters required to flag the boundaries and / or trees?

What methods do you use to determine boundaries and identify trees for cutting?

Activities: Please check all that apply

The total of all check boxes in this section should total 100%. If there is no activity please insert "0" (zero)

1. Felling(Required)

Yes

1. % of Payroll

2. Tree Trimming(Required)

Yes

2. % Payroll

3. Log Road Building(Required)

Yes

3. % Payroll

4. Skidding(Required)

Yes

4. % Payroll

5. Excavation(Required)

Yes

5. % Payroll

6. Blasting/Use of Explosives(Required)

Yes

6. % Payroll

7. Work in Residential Areas(Required)

Yes

7. % Payroll

7. What percentage of logging payroll is derived from residential payroll? Please state the nature of the work and all the Loss Prevention measures take to prevent loss.

8. Slash Burning(Required)

Yes

8. % Payroll

8a. Cont. Slash burning: What controls and safeguards are applied to prevent unintended spread of fire?

8b. Slash burning: Do you only burn at times or under conditions approved by proper state or federal authorities?

Yes

9. Sawmill Operations (including portable)(Required)

Yes

9. % Payroll

10. Woodworking(Required)

Yes

10. % Payroll

11a. Manufacturing cont. : Please state the nature of operations

11. Manufacturing(Required)

Yes

11. % Payroll

12. Use of Aircraft, Helicopter or Watercraft(Required)

Yes

12. % Payroll

13. Work for Utility Companies(Required)

Yes

13. % Payroll

14. Work close to Power Lines(Required)

Yes

14. % Payroll

15. Construction of Bridges, Tunnerls or Dams(Required)

Yes

15. % Payroll

16. Other type of work(Required)

Yes

16. % Payroll

16. Describe other kind of work.

Additional Insured

How many additional insured do you anticipate you will need in the next 12 month?(Required)

Are any of the Additional Insured a Utility Company?

Yes

Underwriting continued

Do you subcontract any of your logging and ancillary work or operations to any third parties?(Required)

Yes

Do all subcontractors provide evidence of insurance equal to or greater than your liability limtis?

Yes

Are you named as "Additional Insured" on Subcontractors policies?

Yes

Have you sustained any losses, insured or uninsured, which would have been covered under this form of insurance had you carried such policy?(Required)

Yes

Please explain details of such loss included date, location and how the loss occured

Have there been any fires or Claims for fires occurring in the last 10 years on the land while you were working on that land?(Required)

Yes

Please explain fires, dates and locations

Please provide details including date and location

Yes

Have you ever had a liability insurance policy cancelled, declined, non-renewed or has any carrier posed any special terms?(Required)

Yes

Do you have Commercial General Liability?

Yes

Commercial General liability is required along with LBF.

We can provide a quot on Logger Broad Form but note. The carrier will required proof of "General Liability" in order to issue / keep the Loggers Broad Form Policy.

What are the General Liability current limits?

What is the name of your current insurance carrier?

What is the current policy term? (start date & expiration date)

Do you require coverage for Oregon Fire Suppression Costs?(Required)

Yes

Do you hold any hold harmless agreements?(Required)

Yes

Please explain the circumstances and provide copies.

You can either upload them here, fax, email or mail the hold harmless agreements. Our fax number is 209 223-3227, email to insurance@athenainsurance.com or Athena Insurance P.O. Box 390, Pine Grove CA 95665.

File Upload of existing documents

Drop files here or

Accepted file types: jeg, pdf, Max. file size: 7 MB, Max. files: 9.

Please use this area to upload such items such as loss runs, current/expiring policy and hold harmless agreement. Multiple file upload is allowed.

I agree to the Terms of Service

APPLICANT INFORMATION

LOGGERS THIRD PARTY PROPERTY DAMGAGE LIABILITY POLICY APPLICATION

Contact Information

Applicants Information

Coverage Required

Payroll “estimates” for the next 12 months in the following

Logging Operations

Activities: Please check all that apply

Additional Insured

Underwriting continued

Commercial General liability is required along with LBF.

APPLICANT INFORMATION

LOGGERS THIRD PARTY PROPERTY DAMGAGE LIABILITY POLICY APPLICATION

Contact Information

Applicants Information

Coverage Required

Payroll "estimates" for the next 12 months in the following

Logging Operations

Activities: Please check all that apply

Additional Insured

Underwriting continued

Commercial General liability is required along with LBF.