United Shortline Insurance Services
8265 North Van Dyke, Port Austin, MI 48467
989-738-6400 * 800-247-2085 * Fax 989-738-6557
Railroad Protective Liability Insurance Application
To receive a quotation for your Railroad Protective Liability Insurance through United Shortline Insurance Services,
please complete the following “mini-application”. This form is writable in your Adobe Acrobat program. You may fax it
to our office for immediate processing. Include all your contact information in the “Broker Information” area.
Railroad: (Named Insured) Phone #:
Address: Fax #:
City, St, Zip:
Contact Name / Title: E-Mail:
Contractor & Address
City, St, Zip
Contractor’s GL Information:
Primary Limits: Excess/Umbrella Limits:
Will RR be listed as Additional Insured on the Contractor’s GL policy? Yes ( ) No ( ).
Has the contractual exclusion for work within 50 feet of railroad been deleted from the contractors
GL or Umbrella Policies? Yes ( ) No ( ).
Name of involved governmental authority (If applicable).
Railroad Protective Limits desired: ______________ Occurrence _______________ Aggregate
Bid Date: ____________ Term: _____________ To: _____________
Description of job:
Is construction: ( ) Parallel to ( ) Over ( ) Under or ( ) On the railroad tracks
Total Job Cost: ______________ Job cost within 50 feet of railroad tracks: ______________
Daily train traffic: (Number of trains) Freight: ______________ Passenger: _______________
Work performed by Railroad: Flagmen / Supervisors: ________________________________
Other Railroad employees? Yes: ____ No: _____