SOLAR ENERGY COVERAGE APPLICATION - PHOTOVOLTAIC ARRAY
Please attach to Basic Application or ACORD 125
Producer Name & Address
Applicant Name
( ) Owner ( ) Contractor or ( )______________
Policy Term_________ to __________
List Additional Insured(s) Name & Address
____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Loss payee:____________________________________________________________________________
Limits of Insurance requested:
$
any one loss
$
while in transit
$
any one location
$
temporary structures
$
newly acquired property
$
removal expense
$
at any one temporary location
Included are:
Upgraded Cleaner or Greener Replacement @25% of physical loss amount
Debris Removal and Recycling Expense @25% of physical loss amount + $100,000 if limits are exhausted
Pollutant Clean Up and Removal @10% of physical loss amount up to %25,000 in 12 month policy period
Limited Fungus Coverage $15,000 per policy year
Other limit requested
Fire Dept Service Charge
$25,000
$
Valuable Papers, Plans, Records & Software
$25,000
$
Loss Data Preparation Expense
$ 2,500
$
___________________________________________________________________________________
Deductible Amount for other than optional coverages $__________ ($5,000 standard minimum in
most locations)
Location (if no address, give geo coordinates for GPS)
_____________________________________________________________________________________
_____________________________________________________________________________________
Description: __________________________________________________________________________
The total value of all property to be covered is $_______________________.
# of panels : _____ total values of all panels: $_____________
KW/MGW capacity per panel:______ KW/MGW capacity for total array :__________
Panel wind speed design:_________ ASTM impact standard for cells ______________________
Manufacturer of Panels: _______________________________________________________________
Cells are ( ) crystalline silicon ; ( ) thin film ; ( ) integrated into a building component
# of inverter(s) _______;
total value of inverters: $_______________
# of transformer(s)_____; total values of transformers: $_________________
Array is: ( )fixed ( )bolted to or ( ) secured by ballast ( ) a foundation or ( ) a building rooftop (age,
occupancy and construction of the building) ____________________________________________
Or ( ) moving panels ( )concentrated photovoltaic (using mirrors)
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Are there transmission lines to be covered? ( ) Yes ( ) No
If so, length ___________(yards) and approximate value $______________
Other equipment to be covered ______________________________________
$_____________
__________________________________________________________________ $_____________
Site security will be provided by ( ) __ft. fence & locked gate ( ) watchman when workers are not
on site; ( ) Security service patrol; ( ) Cameras that ( )are or ( )are not monitored in real time.
( ) Other (describe)_________________________________________________.
Exposures from surrounding area:
_____________________________________________________________________________________
_________________________________________________________________________________
Date installed__________ and by whom___________________________________________________
Past Losses: ( ) None in past five years
Date
Cause of Loss
Gross Amount (including deductible)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
If in the course of construction/installation, Please complete this section.
Contract amount is $______________
Job term: From__________ To_______________
Contractor ( ) is named as an insured above, OR (name & address)
_____________________________________________________________________________________
_____________________________________________________________________________________
Experienc e doing this type of installation ________________________________________
OPTIONAL COVERAGES
_____________________________________________________________________________________
( ) Flood & Surface Water OR ( ) exclude Surface Water and insure only Flood
Limit of Insurance per policy year $__________________ (if sub-limited)
Deductible Amount $_____________
Waiting Period if Business Income is covered ______ (72 hours minimum)
U.S. F.E.M.A . Flood Zone _______ (normally, locations in the flood plain are not eligible)
Past flooding at this location ( ) No ( ) Yes, last date & depth_____________________
_____________________________________________________________________________________
( ) Earthquake & Volcanic Eruption
Limit of Insurance per policy year $__________________ (if sub-limited)
Deductible Amount $____________ OR ____% of location value
Waiting Period if Business Income is covered ______ (72 hours minimum)
( ) Equipment Breakdown Coverage (adds coverage mechanical breakdown & electrical injury loss)
If covering during the course of construction, does the manufacturer’s warranty cover loss to
surrounding property during testing? ( ) Yes (please attach a copy) ( ) No
Any history of loss from these causes at this location? ( ) No ( ) Yes (dates and amount of loss
including deductible for each)______________________________________________________
____________________________________________________________________________________
( ) Ordinance of Law Coverage
Any known ordinance that would prohibit rebuilding at this location? ( ) Yes ( ) No
If yes, ordinance would be triggered at ____% of loss to the Covered Property.
Limits of insurance for A. The undamaged portion is the same as for basic coverage
B. Demolition Cost
$_______________
C. Increased Cost of Construction
$_______________
( ) at the location(s) shown in the Declarations;
( ) at the locations in the attached schedule designated with limits specified for this coverage
_____________________________________________________________________________________
( ) Leased Array Contingent Coverage on property leased to others. Attach copy of your lease.
Do you require that the lessee purchase insurance against physical loss for its replacement cost
and name you (or owner) as a loss payee or an additional insured? ( ) Yes ( ) No (if No,
ineligible for contingent coverage)
Do you obtain evidence of insurance when the value of such property exceeds $50,000?
( ) Yes ( ) No (If No, ineligible for contingent coverage)
Percent of leased property included in the basic coverage limit of insurance above ______%
Limits of Insurance
( ) same as the basic coverage limits of insurance for Any one loss, Any one (lessee)
location, while in transit, temporary location. OR
( )$
Any one loss for leased to others
$
Any one lessee location
$
While held at your location awaiting delivery to a lessee
$
While in transit
Covered Locations:
( ) all locations in the coverage territory; have a total value of $________________
( ) at the location(s) scheduled in the Declarations
( ) Only at the location(s) designated on attached schedule and while in transit.
( ) Inflation Protection $100,000. OR increase limit of insurance to $_________________.
_____________________________________________________________________________________
( ) Business Income & Extra Expense Coverage
Limit of insurance
$_______________
( ) at the location(s) shown in the Declarations;
( ) at the locations in the attached schedule designated with a limit specified for this coverage
The waiting period is _____ hours for perils other than Flood & Earthquake (72 minimum).
_____ ____________________________________________________________________________
Signatures
Producer
Date
Applicant
Date
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