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WA9701-CS051114 (3)
STPAUL St. Paul Travelers Construction ri TRAVELERS Railroad Protective Liability Application The St. Paul Travelers Companies, Inc. 386 Washington Street St. Paul, Minnesota 55102 -1356 APPLICANT INFORMATION 1 Narrb of Insured (RaMAM � — - 17-P I g Ci�G �_ �'� �l "7 50 0 2. Name of wrasues _ LIM"WCOVERAGE L. 4- 4. Limits of Insurance desired: Each Occumance Limit $ �l D 00 j LW Aggregate Limit $ 5. Term of Contract: a. Bid Date b. Proposed Starting Date .....l.l'.�. ds c. Completion Date....... 1,10. dia Y ' ; J ......... /.. d. Job Term In Calendar Days ............1.. ...... . . ... �r��.ifl X.... alb .. ................. ............................... ,2 e. Job Term In Working Days .............................................................._ .......................................................... rl 6. Number of Policies required If more than one insured .................................................... ............................... GENERAL INFORMATION 7. Number of regular trains per day: Passenger Usual speed of trains Freight Unscheduled Switch Movements Please woaln slow orders in effect Please explain stow orders In effect: 1F+ 8. Number of Tracks: Main Line Branch Spur Train Yard O 2004 The St P4UI TmMers Companies, Inc. 56992 Rev. 8-04 Printed In USA Page I of 3 General Information continued 9. Physical characteristics of work Including work performed by subcontractors: a . Total cost of constructfon ............................................................................................. ............................... $ W -S b. Total cost of work within 50 feet of the railroads right -of -way .................................. ............................... $ c. Description of work including unusual operations (Le. caissons, cofferdams, etc.) Attach diagrams If available J A <_ t4 #4 1, U 0 / -' d- - i-J/' LJ a/ I• n t. d. Description of work within 50 feet of the J railroads right -of -way Including at-grade crossings or use of the equipment: '6 0 r e U n L(�r lry ( e. Type of heavy equipment to be : 7 1'4e Ok &." a o P. r TOY f. Project/Contract Nu .... 01 g. Location of work: bil h. Maximum number of contractor employees at any one time: ......................... 0.... ............................... 1 . 1 1. Amount of work perfomied by railroad employees: �X Details of wo►k Cost of work Including wages: ............................ . . ........ ....... ................. .. .. . .. $ ). Amount of wok performed by subcontractors : Y '- •3 1� � Details of work 4Ql 4 - �--- -- o � � tf C C 7r...�i ..Q.�.7f (1.C� .. .... ............................... Cost of work Including wages:. ./ .,.,.t ..... . $ 1' , General Liability Insurance: / k. Does construction Involve movement of track? ................. !1.1.0 ..................... ............ I........................... O Yes If yes, please w#alru: 1. Are flagmen or watchmen employed? ......................................................................... ............................... 94s D No m. is blasting near track expected? ......................! u...................................................... ............................... 0 Yes UV<G If yes, please descxfbe method and exposures: n. What utility lines am In the right -of -way: (' Q&zA& A f01 d I n C P Td le u oi IJ o. Is there any excavation exposure to tracks or underground utlifties, such as pipes or rabies ? ................ 2<3 ❑ No /j)A I /I', D.'11f tarn, a 61.t . A'110 le&", O 2004 The St. Pad T avelers Companies, Inc. 55982 Rev. 8-04 Printed in U.S.A. Page 2 of 3 21M 17 INSURANCE 10. Contractors General Liability Insurance Limits: Of St Pawl Travalws Consinx6on Account, please supply GL Pdicy number). The undersigned Is an authorized representative of the prospective Named insured and certifies that reasonable Inquiry has been made to obtain the answers to these questions. He or she certifies that the answers are true, correct and complete to the best of his/her knowledge and belief. FRAUD WAFTING prof applicable iln Colorado, Hawaii, Nebraska, Ohio, Oklahoma, Oregon, Utah. or Wrmcne Any person who ivrowingly and with Intent to defraud any insurance company or another person files an application for insurance containing commits ulent Insurance act which a eats the pp d er k son , tocrriminal concerning W. s bst civil epeennalttiiess.. to, the District of CoiwibK Louisiana, Maine, Tennessee and Virginia, Insurance benefits may also be denied. COLORADO FRAUD WARNING: R is unlawful to knowingly provide false, incomplete, or misleading facts or Information to an Insunance company for the purpose of defrauding or attempting to defraud the company. Penalties may Include ImprisoranoM fines, denial of inauranc% and dvg damages. Any insurance comparnr or agent of an Insurance company who knowingly provides false, Incomplete, or misleading facts or kdforma8on to a policy holder or claimant for the purpose of detrauc6ng or attempting to defraud the popcy holder or claimant with regard to a settlement or awed payable from insurance proceeds shag be reported to the Colorado Division of insurance within the Department of Regulatory Agenclea HAWAN FRAUD WARNING: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or Imprisonment, or both. OHIO FRAUD WARNING- Any person who, with intent to defraud or knowing that he/she Is facilitating a fraud against an Insurer, submits an application or files a claim containing a false or deceptive statement Is guilty of Insurance fraud. OKLAHOMA FRAUD WARNING: Any person who knowingly, and with Intent to injure, defraud or deceive any Insurer, makes any claim for the proceeds of an Insurance policy containing any false, Incomplete or misleading Information is guilty of a felony. FLORIDA REQUISISIM. producer's License No. ApentBrolaer Date //— S — Date Important Note: This application Is not a representation that coverage does or does not exist for any particular claim or loss, or type of claim or loss, under any Insurance policy Issued by St. Paid Travellers. Whether coverage exists or does not exist for any particular claim or loss under any such policy depends on the facts and circumstances Involved in the claim or loss and all applicable wording of the policy actually issued. © 2004 The St. PaWlTwelm Companles, Inc. 55992 Rev. 8-04 Printed In U.SA Page 3 of 3 11. Attach any contract or indemnification between Railroad and Contractor.