Cossio Insurance Agency Party Equipment Rentals Application
ADDITIONAL QUESTIONS
EMPLOYEE SURVEY
During the 10 ten years, have you or an applicant been convicted of any degree of arson?
Yes
No
In Rhode Island, this question must be answered by any applicant for property insurance. Failure to disclose the
existence of an arson conviction is a misdemeanor punishable by a sentence of up to one year of imprisonment.
Number of Employees:
Minimum age of operators/attendants:
Any employees leased to or from other employers?
Yes
No
Is there a labor interchange with any other business or subsidiaries?
Yes
No
If you do have a labor interchange with other business or subsidiaries, explain:
Do you subcontract any work?
Yes
No
If you do subcontract any work, please describe what:
Do your subcontractors carry coverages or limits less than yours?
Yes
No
Are subcontractors allowed to work without providing you a certificate of insurance?
Yes
No
Do you lease equipment to others with or without operators?
Yes
No
What limits of liability do you require of your subcontractors?
RISK ASSESSMENT
Do you have a formal safety program?
Yes
No
Please send attachment:
Any policy or coverage declined, cancelled or non-renewed during the prior 3 years? ( N/A in Missouri)
Yes
No
Please send attachment:
Any past losses or claims relating to sexual abuse or molestation allegations, discrimination or negligent hiring?
Yes
No
Please send attachment:
Any operations sold, acquired, or discontineud in the last 5 years?
Yes
No
Please send attachment:
Have you been active in or currently active in any joint ventures?
Yes
No
Please send attachment:
Is there a swimming pool on premises?
Yes
No
Please send attachment:
Have any crimes occured or been attempted on your premises within the last 3 years?
Yes
No
Please send attachment:
Does your website or brochures make statements that warranty or guarantee the safety of your equipment?
Yes
No
Please send attachment:
Is there a written rental agreement between you & your client?
Yes
No
Does the rental agreement contain a hold harmless or indemnity clause?
Yes
No
Please send attachment:
Do you have written Equipment Maintenance procedures?
Yes
No
Please send attachment:
Do you have written Employee Training procedures?
Yes
No
Please send attachment:
Please make sure that you have completed everything to the best of your knowledge before going to the next page.