Loggers Broad Form

Please check all the boxes that apply to your operations now or that will apply to you operations over the next 12 months.

This form is a fact finder. Please help us to determine which of our insurance markets are the best fit for your business. Thank you.

1. Logging or Tree removal in Residential areas where the employee and /or owner "payroll is over 20%"

Loggers General Liability or Loggers Broad Form

If you need a consultation please call 209 223-1870. All Loggers Broad Form Insurance requires General Liability also. So, if you need for example "Loggers Broad Form" coverage and DO NOT currently have general liability please check "Both"

Need by Date (please allow at least 5 days leeway at a minimum)*

Many quotes can be provided within 5 working days. Loss runs are required if you have prior insurance. (5 years if possible)

Choose the type of quote(s) you require*

Both Loggers Broad Form and General Liability

General Liability Only

Loggers Broad Form Only

Both Loggers Broad Form, General Liability and more

Workers Compensaton

Trucking / Transportation

Inland Marine / Equipment

Please explain "other"

LOGGERS THIRD PARTY PROPERTY DAMAGE QUESTIONNAIRE

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*

Cell 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

Number of employees*

Number of years in business*

Briefly describe your experience*

Coverage Required

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?*

Commercial General liability is required along with LBF.

We can provide a quote 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.

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