Application Form HYDROELECTRIC APPLICATION SUPPLEMENT LIABILITY Application Step 1 of 11 - PROJECT INFORMATION 9% Insured Name: First Last Mailing AddressEmail Address I. PROJECT INFORMATIONNamed insured is: Owner/Operator Contract operator Owner/Developer General contractor Other (check all that apply) Project Name:Exact Site Location:Inspection Contact Name & NumberIs the facilityrun of river?impoundment?diversion?pump storage?Annual production: (KWH)Rated capacity: (MW)Annual power sales: $ Project is:UrbanRuralRemoteIs the project operated/maintained byyou?others?Is the projectmanned?unmanned?If unmannedFrequency of visits isDailyweeklymonthlyIs there automatic notification to supervisor in the event of emergency?yesnoTravel time from remote monitor to site:Does the project include adamdiversion(Submit a dam safety inspection report if available.)Is itowned?leased?who is the owner?Type of dam:concrete gravitytimber cribarchembankmentbuttressSize:lengthheightwidth Year builtReservoir capacity:Are flashboards used?YesNoAre theymechanicalwoodenWhat is the head distance:Detail the spill ways or overflow facilities in place:Provide lead times of critical equipment in the event of failure (i.e. turbines):Check if applicable protective devices for this project. Over speed trip Low lube oil High vibration Wicket gate protection Ground fault trip Reverse current Over c urrent trip Loss of excitation Lightning protection Please attach a copy of the most recent FERC report (if applicable)Please attach a 5-year loss history (if applicable) II. GENERAL LIABILITY COVERAGE INFORMATIONIf you are requesting General Liability Coverage, please complete this section.Limit of Indemnity$1,000,000$2,000,000$5,000,000Effective Date:Is the site secured with fences, locked gates or other physical barriers?YesNoAre there hazard warning signs at the premises?YesNoIs the public allowed access to the premises?YesNoAre there any recreational facilities on or adjacent to your premises?YesNoAre there any dams, reservoirs, or other hydroelectric facilities upstream that can affect your operation?YesNoDescribe:What structures, (mobile homes, residential areas or commercial areas), are downstream of the plant, ? How far are they away from the plant? Are the banks of the river tall enough down stream to contain all of the water in case of a total water containment failure? Does the plant use a dam or diversion? If the plant has a dam, is it high, medium or low hazard? If the plant has a high hazard dam, does the plant have an emergency plan on file with FERC? Is the dam or diversion in an urban or rural location?Do you have a written emergency action plan?YesNoWhen? III. PROPERTY COVERAGE INFORMATIONIf you are requesting Property Coverage, please complete this section.A. PowerhouseYear Built:Has the powerhouse been refurbished?YesNoWhen?Is there remote monitoring?YesNoDetails of the site security:History of flooding of buildings, structures, equipment on site:Flood Zone: Build above the 100 year Flood Plain?YesNoB. Turbine(s)Turbine 1Type Pelton Kaplan Francis Bulb RPM:CFS (Flow ):Year Built:Rebuilt:YesNoDate Rebuilt: by Whom: Turbine 2Type Pelton Kaplan Francis Bulb RPM:CFS (Flow ):Year Built:Rebuilt:YesNoDate Rebuilt: by Whom:Turbine 3Type Pelton Kaplan Francis Bulb RPM:CFS (Flow ):Year Built:Rebuilt:YesNoDate Rebuilt: by Whom: Generator(s)Generator 1TypeSynchronousInductionSizeYear Built:RebuiltYesNoDate by Whom:RPM:Generator 2SizeTypeSynchronousInductionYear Built:RebuiltYesNoDate by Whom:RPM:Generator 3SizeTypeSynchronousInductionYear Built:RebuiltYesNoDate by Whom:RPM: Transmission and DistributionTransformer 1Size:Transformer 2Size:Transformer 3Size:Do you own transmission lines?YesNoHow long is it?Dam and DiversionIs the dam or diversion structure to be insured?YesNoPlease state values:DamDiversionIf the dam or diversion is leased, what is the replacement cost of improvements and betterments? $ F. PenstockIs the penstock to be insured?YesNoValues:Type:SteelConcreteIs the penstockabove groundundergroundG. Property LimitsPlease attach a statement of values worksheet Declaration and SignatureThe undersigned declares that to the best of his or her knowledge and belief the statements and in formation in this application statement are true. The company is hereby authorized to make any investigation and inquiry in connection with the application statement that it deems necessary.Dated: Signed(First Named Insured)TitleSubmitted by:(Producer)Date FALSE INFORMATION 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. 100% REPLACEMENT COST VALUESOrganization:Project:Machinery Unit 1Turbines & ValvesGeneratorSwitchgear & ControlsTransformersTotal 1Machinery Unit 2Turbines & ValvesGeneratorSwitchgear & ControlsTransformersTotal 2Machinery Unit 3Turbines & ValvesGeneratorSwitchgear & ControlsTransformersTotal 3Overall Total BuildingPowerhouseCivil Works & Gates & SubstationTrashracksTransmission LinesPenstocksGatehouseBuilding Personal PropertyPowerhouseCivil Works & Gates & SubstationTrashracksTransmission LinesPenstocksGatehouseVALUEPowerhouseCivil Works & Gates & SubstationTrashracksTransmission LinesPenstocksGatehouseTotalOverall Direct Damage Values TotalBusiness Interruption Value TotalOwner or RepresentativeDate PhoneThis field is for validation purposes and should be left unchanged.