Application Form EIB Biomass Application EIB Biomass Application Step 1 of 9 - PROJECT INFORMATION 11% Insured Name: First Last Website Years in BusinessYears of ExperienceExperience in fieldI. PROJECT INFORMATIONNamed insured is: Owner/Operator Contract operator Owner/Developer General contractor Other (check all that apply) Project Name:Location:Is 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?Frequency of visits isdailyweeklymonthlyIs there automatic notification to supervisor in the event of emergency?yesno II. EQUIPMENT / CONTRACTOR INFORMATIONAny equipment rental?YesNoWhat percent of work is subcontracted out?Are subcontractors always insured?YesNoAre you named as an additional insured on all subcontractors’ policies?YesNoDo you have a written contract with your subcontractors?YesNo III. GENERAL LIABILITY COVERAGE INFORMATIONIf you are requesting Property Coverage, please complete this section.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?YesNoDo you have a written emergency action plan?YesNo III. PROPERTY COVERAGE INFORMATIONIf you are requesting Property Coverage, please complete this section.A. PowerhouseYear Built:Has the powerhouse been refurbished?YesNoWhen?Was the powerhouse designed above the 100 year flood plain?YesNoB. Turbine(s)Turbine 1Type Pelton Kaplan Francis Bulb RPM:Year Built:Rebuilt:YesNoDate Rebuilt: by Whom: Turbine 2Type Pelton Kaplan Francis Bulb RPM:Year Built:Rebuilt:YesNoDate Rebuilt: by Whom:Turbine 3Type Pelton Kaplan Francis Bulb RPM:Year Built:Rebuilt:YesNoDate Rebuilt: by Whom: Generator(s)Generator 1SizeTypeSynchronousInductionYear Built:RebuiltYesNoDate by Whom:RPM:Generator 2TypeSynchronousInductionSizeYear Built:RebuiltYesNoDate by Whom:RPM:Generator 3TypeSynchronousInductionSizeYear Built:RebuiltYesNoDate by Whom:RPM: Transmission and DistributionTransformer 1Size:Do you own transmission lines?*YesNoIf yes, how long is it?*Transformer 2Size:Do you own transmission lines?*YesNoIf yes, how long is it?*Transformer 3Size:Do you own transmission lines?*YesNoIf yes, how long is it?*Do you own transmission lines?YesNoHow long is it? Declaration and SignatureThe undersigned declares that to the best of his or her knowledge and belief the statements and information 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)TitleEmail address Phone NumberCell Phone NumberMailing address(First Named Insured) Submitted 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.CAPTCHACommentsThis field is for validation purposes and should be left unchanged.