propane and natural gas supplemental … supplemental.pdfpropane and natural gas automobile and...

1. To be completed by applicant and saved to your local computer.

2. Completely answer all questions. The information requested is in addition to that which your agent will provide in the appropriate ACORD application(s).

3. If you require more space, please use the blank page at the end of this supplemental and reference the applicable ques-tion number you are responding to.4. This supplemental application must be signed and dated by an authorized representative of the applicant.

PROPANE AND NATURAL GASSUPPLEMENTAL

APPLICATIONSwww.fairmontspecialty.com/pc-programs/propane-retail-wholesale

General Information Supplemental Application ........................................................................Page 2Automobile And Driver Supplemental Application ........................................................................Page 3Propane Supplemental Application ........................................................................Page 4, 5LP Gas Truck Fabricators Supplemental Application .......................................................................Page 6, 7Petroleum & Fuel Oil Supplemental Application .......................................................................Page 8, 9Convenience Stores Supplemental Application .......................................................................0, 11Natural Gas Supplemental Application ........................................................................Page 12, 13Leak Survey Recap Supplemental Application ........................................................................Page 14Water Utility Supplemental Application ........................................................................Page 15Fraud Notice, Applicant Signature, and Producer Signature ........................................................................Page 17, 18

Page 1

Please complete pages needed according to your operations:

www.fairmontspecialty.com/pc-programs/propane-retail-wholesale

PROPANE AND NATURAL GASGENERAL INFORMATION

SUPPLEMENTAL APPLICATION


1. Applicant Name: ___________________________________________________ Effective Date:___________________

2. List each Named Insured, the date started/acquired and description of operations: Name: ____________________________________________________________________________________________

Date started/acquired: ______________ Operations: ______________________________________________________

Name: ____________________________________________________________________________________________

Date started/acquired: ______________ Operations: ______________________________________________________

Name: ____________________________________________________________________________________________

Date started/acquired: ______________Operations: _______________________________________________________

(Ownership breakdown will be requested if more than one requested Name Insured)

3. Has there been a change in management in the past 5 years? If so, please explain. _______________________________________________________________________________________________________________________________

4. Please list all industry associations of which you are a member. _____________________________________________

5. Please provide a narrative description of all your current operations: __________________________________________________________________________________________________ 6. Do you have any past, or discontinued operations, not described above? Yes No If yes, please describe: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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PROPANE AND NATURAL GASAUTOMOBILE AND DRIVER


www.fairmontspecialty.com/pc-programs/propane-retail-wholesale1. What is your annual employee turnover ratio? ___ % Drivers ___ % OthersApplicant employs _____ persons, as follows: ___Tractor/Trailer Drivers ___Outside Sales ___Servicemen___Tank Truck Drivers ___ Plant Mgrs. ___Clerical___ Maintenance ___Mechanics ___Other (describe) ____________________ 2. What are your requirements for hiring drivers (experience, written / road testing, etc.): ___________________________________________________________________________________________________________________________

3. Do you order and review MVRs prior to hiring all drivers? Yes No What would disqualify a driver? _________________________________________________________________

4. Do any drivers have: a DWI; more than 3 moving violations and/or accidents in the last 3 years; more than 2 moving violations and/or accidents in the last 2 years? Yes No If yes, please identify on the driver list. ____________________________________________________________

5. Do you have a drug/alcohol testing program? Yes No If yes, describe your criteria for pass/fail (zero tolerance, probation, etc.) ________________________________

6. Have any exceptions been made to your drug/alcohol policy? Yes No If yes, provide details: _________________________________________________________________________

7. How are driver’s activities monitored? _________________________________________________________________

8. Do you transport property of others? Yes No If yes, advise commodities hauled, frequency and radius:______________________________________________ ____________________________________________________________________________________________

9. Do you have a written policy on personal use of company vehicles? Yes No If yes, attach a copy.

10. Are employees, or your family members, allowed personal use of company vehicles? Yes No If yes, describe who and under what conditions: ____________________________________________________

11. Do you have any tank trailers that are switched between propane and anhydrous ammonia? Yes No

12. Do you have any operations related to converting vehicles from gas/diesel to propane power? Yes No If yes, annual sales: $ __________________

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PROPANE AND NATURAL GASPROPANE



1. Do you have a bulk storage plant? Please list below. Address Number of

TanksGallon Capacity

of Each TankOccupancy of Non-owned structures within 500 feet

2. Provide LP gallons sold by type of customer:

Type of Customer LP Gallons No. Of CustomersRetail – delivered to personal end users Commercial – delivered to commercial end users and agricultural customersWholesale - sold to other Dealers and/or Distributors for resale Bottle Fill / Cylinder Exchange Drop Shipped – picked up from non-owned terminal and delivered direct to customer

Brokerage – paper transaction only – no physical possession of (prod-uct)Other - Describe

OUT OF GAS AND CUSTOMER SAFETY

3. What percentages of your customers are? Will Call: ___ % Automatic Fill: ___ %

4. What percentage of you customers are? Leased Tanks ___ % Customer Owned ___ %

5. How many out of gas deliveries do you average per year? ____________________ 6. Do you have a written out of gas policy for employees to follow? Yes No

If yes, please attach a copy. 7. Do you require an adult to be at home for out of gas deliveries? Yes No

8. Do you perform and document a leak test? (leak test must include pressure and time held to be valid) Yes No

9. Do you return appliances back in operation. (Light the pilot lights) Yes No

10. If a leak check cannot be performed and the tank is filled, is a POL lock or other method used to prevent the customer from turning on the gas? Yes No


11. Are leak checks performed and documented for the following:New Customer (Leased Tanks) Yes No Out-of-Gas Instances Yes NoNew Customer (Customer Owned Tanks) Yes No Change in Tenant Yes NoService Work Customer with interruption of service Yes No Other (Describe) Yes No

12. Do you perform a GAS Check, “Safety Check”, or state required form, to document the appliances used (manufacturer, model/serial #, shut off valve), tank/cylinder inspection, regulator flow and lock, and leak checks? If yes, attach a completed sample Yes No

13. What percentage of your existing customers has a documented leak check in their file including the pressure and time held? ___ %

14. Do you send customers safety information annually and document who receives it? Yes No

15. Do you have any jurisdictional systems, where you are providing propane from a single container to more than 9 resi-dential customers or 2 or more commercial businesses? Yes No

(Attach copies of leak survey recap for each of the last 4 years for each juristicional system)

16. Do you have any propane cylinder filling dispensing stations leased to others for filling propane cylinders? Yes No If yes, how many? ____________________ If yes, do you have documentation of training for all persons filling cylinders? Yes No If yes, do you have certificates of insurance from the lessee (operator)? Yes No

17. Are you registered to visually requalify cylinders? Yes No If yes, do you keep a log? Yes No

18. Do you sell, install, and/or service any of the following: furnaces, other gas appliances (fireplaces, hot water heaters, space heaters, ranges), BBQ grills, wood/coal stoves, spas/hot tubs, electric appliances. Yes No If yes, describe: ______________________________________________________________________________ Annual sales $____________________

19. Do you perform any HVAC work? Yes No If yes, provide annual payroll $____________________

20. Do you lease, loan or rent construction heaters to others? Yes No If yes, how many rented/leased annually? Individuals____________________ Contractors____________________ Provide copy of written rental agreement.

EMPLOYEE TRAINING1. Do employees have documented training for job functions they perform related to the handling and transportation of propane? Yes No

2. Do employees participate in CETP and/or other required state training? Yes No

3. Is refresher training for all employees provided and documented for all the job functions performed in accordance with NFPA 58? Yes No

4. Do all appropriate employees have hazardous materials training within 90 days of employment and every 3 years thereafter? Yes No

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PROPANE AND NATURAL GASLP GAS TRUCK FABRICATOR



1. Please provide annual sales for the following work:

Truck fabrication/assembly $Cargo Tank Test $

Trailer LPG/NH3 assembly $Mechanical Repair $

2. Do you perform any of the following?

a) Engine repair or modification Yes No b) Brake work Yes No c) Periodic “DOT” annual inspections of vehicle chassis/engine Yes No d) Alteration or Modification of the chassis Yes No e) Repair lift gates Yes No f) Install, repair or work on cranes Yes No g) Repair outriggers on crane trucks Yes No h) Other (please describe): _____________________________________________________________________ 3. Are all mechanics certified ASE Truck Equipment Technicians? Yes No

4. Do you have (check all that apply)? R Stamp VR Stamp Other: Describe _____________________________________________________

5. Last approval from National Board of Boiler & Pressure Vessels ____________________ CT#____________________

6. Do you weld on cargo tanks? Yes No

7. Do you repair ASME Code “U” stamped cargo tanks? Yes No

8. Do you modify/stretch, or replace cargo tanks? Yes No If yes, describe:______________________________________________________________________________

9. Do you make up your own hoses by cutting to length and attaching hose ends? Yes No If yes , are pressure test records kept and hoses properly marked? Yes No

10. Do you hire trucking companies or personnel to transport vehicles to the customer? Yes No If yes, list names and do you obtain certificates of insurance? __________________________________________

11. Do you subcontract any part of your operation? Yes No If yes, describe: ______________________________________________________________________________

12. Do you have any dealer/transporter plates? Yes No If yes, how many: _______________

13. If you transport vehicles, what is the average radius in miles? _______________


14. Do you rent or lease any vehicles to others? Yes No If yes, describe: ______________________________________________________________________________

15. Do you maintain quality control records of all work done and all parts installed? Yes No How long are records kept?_____________________________________________________________________

16. Is a quality control checklist completed? Yes No

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PROPANE AND NATURAL GASGASOLINE/DIESEL/FUEL OIL


www.fairmontspecialty.com/pc-programs/propane-retail-wholesale1. Provide gallons sold by type of customer

PETROLEUMType of customer Petroleum Fuel Oil Other/Type

Retail – sold to personal end usersCommercial – sold to commercial end usersWholesale – sold to other dealers or distributors for resaleDrop Shipped – picked up from non-owned terminal and delivered direct to customerBrokerage – paper transaction only – no physical possession of product

2. Do you have bulk plant storage? (NON-LPG) Please List Below: Address

Type of FuelAbove Ground/Gallons CapacityBelow Ground/Gallons CapacityIs the tank diked? Yes No Yes No Yes No Yes NoWhat type of material is dike made of?Type of dike flooring materialFenced? Yes No Yes No Yes No Yes NoType of leak monitoring system

3. Do you have a security plan in conformance with DOT HM 232? Yes No

4. Do you have an EPA approved Spill Prevention Control and Countermeasure Plan in place? Yes No

5. Do you do any loading/unloading from any kind of watercraft or barges? Yes No

6. Do you do any direct fueling of aircraft or watercraft? Yes No

7. Are all delivery vehicles equipped with spill containment equipment? Yes No

8. Do you have any agreements in place with HAZMAT cleanup contractors for spills in transit? Yes No


9. Are all delivery vehicles equipped with emergency communication devices and emergency phone numbers for HAZMAT cleanup contractor and claim reporting? Yes No

10. For gasoline products, are all vehicles or loading racks equipped with deep spout tanks or bottom filling tanks? Yes No

HOME HEATING OIL1. For a basement fill, do you confirm the fill line is connected to the tank prior to each fill? Yes No

2. For a basement fill, do you confirm there is a working vent/whistle alarm in place near the fill pipe? Yes No

3. If a fill line is no longer in use, has it been properly disabled to prevent filing? Yes No

4. Do you have a “No Whistle – No Fill” policy? Yes No

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1. Do you have a C Store location? Please list below. Address

Hours of OperationInside or Outside Surveillance Cameras? Inside

Outside Both None

Inside Outside Both None


Any check cashing for a fee operations? Yes No Yes No Yes NoATM’s located inside or outside? Inside

Outside Both None



Car wash automatic or manual (wand/brush operated by customer)?

Auto Manual None

Auto Manual None

Auto Manual None

Any propane bottle exchange or bottle fill operations?

Bottle Exchange Bottle Fill None



What are the average/max. amounts of cash on the premises?

___________Avg.

___________Max

___________Avg.

___________Max

___________Avg.

___________MaxAre there any deep fat fryers for cooking?

If yes,

- Is there a automatic extinguishing system in hood, duct, and covering cooking surfaces?

- Is there a thermostatic control with auto-matic fuel shutoff?

- Have you contracted for cleaning of the hood, ducts filters?

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

What type of alcohol is sold? Beer Wine Liquor

Beer Wine Liquor

Beer Wine Liquor

Alcohol annual receipts $

PROPANE AND NATURAL GASCONVENIENCE STORE




2. Have arrangements been made for prompt removal of snow and ice? Yes No If yes, describe: _______________________________________________________________________________________________________________________________________________________________________________ 3. Are any firearms kept or brought on to the premises by employees? Yes No If yes, describe: _______________________________________________________________________________________________________________________________________________________________________________ 4. Are there any machines (games of chance) on any of the premises that award money, or prizes, points/tokens that can be redeemed for merchandise? Yes No If yes, describe: _______________________________________________________________________________________________________________________________________________________________________________ 5. Do any of the premises have showers or sleeping facilities? Yes No If yes, describe: _______________________________________________________________________________________________________________________________________________________________________________ 6. Do any of the premises sell fireworks or allow fireworks to be sold by others at any time during the year? Yes No If yes, describe: _______________________________________________________________________________________________________________________________________________________________________________ 7. Do you sublease any part of the premises to another business operation (motor vehicle repair/sales, restaurants, Laundromats, etc.)? Yes No If yes, do you get a Certificate of Insurance? Yes No

8. Comments on frequency of deposits, use of time lock safes, and any measures used to reduce crime exposure:____________________________________________________________________________________________________________________________________________________________________________________________________ 9. What type of training do employees receive in age verification for alcohol and cigarette sales?____________________________________________________________________________________________________________________________________________________________________________________________________

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PROPANE AND NATURAL GASNATURAL GAS


www.fairmontspecialty.com/pc-programs/utilities-natural-gas-water-sewer1. Identify all operations (please check all that apply).

Natural Gas Utility Own/operate Natural gas wells Caverns used for underground Storage Sell/service/install household appliances CNG/LNG stations Underground Storage Tanks Sewer Utility Electric Utility Telephone Utility Water Utility *(complete water supplemental) Propane Sales/Delivery *(complete propane supplemental) Other (describe): _________________________________________________________________________________

2. Do you own or operate any LPG or LNG peak-shaving facilities? Yes NoIf yes complete table below:

LPG or LNG peak-shaving Plant Location # and capacity (w.g.) of tanks at location

Provide the last 4 years of your DOT FM7100 forms and leak survey recap forms for review.

3. If there is cast iron pipe in your system, describe your replacement program:__________________________________ __________________________________________________________________________________________________

4. Annual budgeted payroll:Principal Duties No. Of Employees Annual Budgeted PayrollManagers/Superintendents whose duties are inside the office

$

Managers/Superintendents whose duties are outside the office

$

All other employees who work outside (e.g.: construc-tion, meter readers, service/repair, etc.)

$

Clerical $Note: Outside employees working for more than one department, payroll should be prorated by department

EMPLOYEES AND TRAINING1. Is there any interchange of labor between the Gas Utility and any other operation? Yes No If yes, please describe: _________________________________________________________________________ _________________________________________________________________________2. Is there an operator qualification program to train all employees per pipeline safety standards? Yes No

3. Is all training documented? Yes No

www.fairmontspecialty.com/pc-programs/utilities-natural-gas-water-sewer

SYSTEM SAFETY1. Are the business districts leak tested annually? Yes No How often are the residential districts leak tested? __________________________________________________ Performed by: company employees outside contractor (specializing in leak testing service)

2. All leaks repaired from the last testing? Yes No If not, explain: ______________________________________________________________________________

3. Do you maintain a written log of complaints/suspected leaks and action taken? Yes No

4. If gas is detected and cannot be repaired, is the gas shut off and system locked until repairs made? Yes No

5. Do you have an operations and maintenance plan? Yes No If yes, date of last review/revision:________________________________________________________________

6. Is all gas odorized that is distributed to your customer? Yes No Who odorizes the gas and how often is it checked?___________________________________________________

7. Do you send customers safety information annually and document? Yes No

8 Have you had an unaccounted for gas percentage over 3% in the past 3 years? Yes No Reason for going above 3%? ___________________________________________________________________ Corrective action taken to reduce to 3% or below? _________________________________________________ _________________________________________________

9. Who performs line location? Company employees Contractors

10. Is a leak test performed after an interruption of service? Yes No

11. Is the leak test documented? Yes No

12. Do you light pilot lights after an interruption of service? Yes No

13. When service is disconnected do you turn off the service valve and attach a lock? Yes No

14. Are your regulator stations completely fenced and protected from vehicle damage? Yes No

15. The regulator station relief valves are tested by: Company personnel Contractor Other

16. Are any contractors hired to install piping, regulators or meters? Yes No If yes, annual cost: ____________________ If yes, are certificates of insurance obtained? Yes No

17. Are welders hired to weld steel pipe? If yes, annual cost: ____________________ If yes, certificates of insurance obtained? Yes No

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PROPANE AND NATURAL GASLEAK SURVEY RECAP


www.fairmontspecialty.com/pc-programs/utilities-natural-gas-water-sewerPlease provide the last 4 years leak recap below:

Date(s) SurveyedSCOPEMiles of pipeline in-spected% of system inspected# of services inspected% of total services inspectedRESULTS# of leaks detected# of pipeline leaks detected# of services leaks detected# of grade 1 (C) leaks detected# of grade 2 (B) leaks detected# of grade 3 (A) leaks detected

CLASSIFICATION METHOD

Number of grade 1 (C) leaks: 75% to 100% CGINumber of grade 2 (B) leaks: 15% to 75% CGINumber of grade 3 (A) leaks: 0% to 15% CGI

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PROPANE AND NATURAL GASWATER UTILITY


www.fairmontspecialty.com/pc-programs/utilities-natural-gas-water-sewer1. Water supply is drawn from: Lakes/Rivers Watershed Reservoirs Wells Other (describe) __________________

2. Who performs water quality testing? __________________________________________________________________

3. How is your water supply protected? A. Are owned wells fenced and locked? Yes No

B. Is the public permitted access to lakes, rivers or reservoirs for: Fishing Boating Swimming Skiing Other

C. Are open reservoirs/surface water areas fenced? Yes No

7. Are tanks regularly inspected by engineers? Yes No

8. Have you ever been cited for an unsafe water quality issue? Yes No If yes, describe: ______________________________________________________________________________

9. Describe type of pipe used:

Type % of system % of pipe in service less than 10 years

% of pipe in service 11-15 years

% of pipe in service more than 15 years

Cast ironAsbestosLeadPlasticOther (describe)

10. Describe your water supply tanks:

Address Age Capacity (gallons) Construction Type

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PROPANE AND NATURAL GASADDITIONAL SPACE



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Please reference applicable question from supplemental.


ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM 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 AND SUBJECTS THAT PERSON TO CRIMINAL AND CIVIL PENALTIES. (Not applicable in AL, AR, CO, DC, FL, KS, KY, LA, MD, ME, NJ, NM, NY, OH, OK, OR, RI, TN, VA, VT, WA or WV - see Additional Fraud Notices attached hereto for these States).

ADDITIONAL FRAUD NOTICES

NOTICE TO ALABAMA, ARKANSAS, LOUISIANA, NEW MEXICO, RHODE ISLAND AND WEST VIRGINIA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an applica-tion for insurance is guilty of a crime and may be subject to fines and confinement in prison.

NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.

NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a state-ment of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

NOTICE TO KANSAS APPLICANTS: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act.

NOTICE TO KENTUCKY APPLICANTS: 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.

NOTICE TO MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance com-pany for the purpose of defrauding the company. Penalties may include imprisonment, fines or denial of insurance benefits.

NOTICE TO MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insur-ance policy is subject to criminal and civil penalties.

NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim 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, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he 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.

NOTICE TO OKLAHOMA APPLICANTS: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any in-surer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

NOTICE TO OREGON APPLICANTS: Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a false statement as to any material fact may be violating state law.

NOTICE TO TENNESSEE, VIRGINIA AND WASHINGTON APPLICANTS: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include impris-onment, fines, and denial of insurance benefits.

NOTICE TO VERMONT APPLICANTS: Any person who knowingly presents a false statement in an application for insur-ance may be guilty of a criminal offense and subject to penalties under state law.

The undersigned declares that to the best of his or her knowledge and belief the statements and representations made herein and in any attachments appended hereto and/or incorporated herein by reference are true and complete and that no material facts have been misstated, misrepresented, suppressed or concealed. The signing of this application does not bind the undersigned to purchase insurance, nor does review of the application bind any insurer to issue a policy. It is agreed, however, that this application shall be the basis of the contract should a policy be issued. If there is any material change in the answers to the questions provided herein or in any of the attachments appended hereto and/or incorporated herein by reference prior to the effective date of the insurance policy, the applicant must immediately notify the insurer in writing and the insurer reserves the right in such instance to modify or withdraw any quotation or binder that may have been issued. The undersigned also represents and warrants that he or she is authorized on behalf of the applicant to complete and sign this application on its behalf.

__________________________________________ ________________________________________Applicant Name (Printed) Applicant Title__________________________________________ ________________________________________Applicant Signature* Date

* ELECTRONIC SIGNATURE AND ACCEPTANCE

PRODUCER INFORMATION:

__________________________________________ __________________________________________Producer Name (Printed) Producer Signature*________________________ _____________________ _________________________Agency Name Agency Code License Number

* ELECTRONIC SIGNATURE AND ACCEPTANCE

* You can apply your signature to this form electronically by checking the Electronic Signature And Acceptance box below your signature line and by then either applying your electronic signature to this form or by typing your name above your signature line on this form. By doing so, you hereby consent and agree that your use of a key pad, mouse, keyboard or other device to accomplish the foregoing constitutes your signature, acceptance, and agreement as if actually signed by you in writing and has the same force and effect as a signature affixed by hand. Further, you agree that the lack of a certification authority or other third party verification will not in any way affect the validity or enforceability of your signature or any resulting contract.

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C&F, Crum & Forster, and Fairmont Specialty are registered trademarks of United States Fire Insurance Company. Crum & Forster is comprised of leading and well-established property and casualty business units and insur-ance companies including United States Fire Insurance Company, The North River Insurance Company, Crum and Forster Insurance Company and Crum & Forster Indemnity Company.

propane and natural gas supplemental … supplemental.pdfpropane and natural gas automobile and...

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