• The first time you complete an application an account will be set up for you at www.123ocp.com and a password emailed to you.
• All of your quotes, policies and invoices will be in your account on the website. When you go to www.123ocp.com you will put in your email address and password to get to your account.
• You can complete an application to get a quote and then go back in to bind coverage if you are awarded the job.
• You can edit an application to change the information by going to unbound quotes, picking the correct one and clicking on edit. Change what you need to and both quotes will remain in your account.
• There is NO backdating of coverage. The current date is the earliest that coverage can be bound.
• The premium is due upon receipt of the invoice. If the entire premium is not received within 10 days of the effective date, cancellation will be issued to the Railroad.
• The policy should be quoted for the entire term of the project.
• There are no renewal policies issued. If the contract is extended you will have to notify us PRIOR to the expiration date of the policy in order to have it extended.
• There is no backdating of extensions – if the policy already expired you will need to enter a new one.
• YOU CAN EMAIL US AT SUPPORT@123OCP.COM OR CALL US AT 866-883-7692

Name of Applicant:	First: Last:	Email Address:
Company Name:		Office Phone #:
Company Address:	CityStateZip	Mobile Phone #:

Agent Information
Agency Name:
Agent Name:	Stan Szczurek
Agent Address:	1285 Drummers Lane Suite 305 Wayne, PA 19087
Agent Phone #:	866-883-7692
Agent Email:	sszczurek@123ocp.com
Agent Code:	HUDSZ1

Railroad Information
Insured Name (Railroad):	Is the insured "Norfolk Southern Corporation"?     Yes   No Is the insured "BNSF Railway Company"?     Yes   No (Enter the insured name below)
Insured Address:	City State Zip Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Project Information
Effective Date:  (mm/dd/yyyy format) Expiration Date:    (mm/dd/yyyy format)
Work Performed For:	Railroad Govt Authority/Other --->	Name (Work Being Perfomed For) Address CityStateZip
Does your work include any bridge work?: Yes No
Explain Bridge Work: (Note: Any project with bridge work and a 5MM/10MM limit will be a referral)
Does the project involve overhead lines and/or wire work?: Yes No (Note: If other types of construction are involved, then answer "No")
Parallel (along the tracks)     ---> Perpendicular to the tracks (over the tracks)		Number of Feet (Length): 0 - 250 251 - 500 501 - 1,000 1,001 - 2,000 2,001 - 4,000 4,001 - 6,000 6,001 - 8,000 8,001 - 10,000 Over 10,000
Number of Installations (over the tracks):
Does the project involve underground lines/wire and/or underground pipe work?: Yes No (Note: If other types of construction are involved, then answer "No")
Parallel (along the tracks)     ---> Perpendicular to the tracks (under the tracks)		Number of Feet (Length): 0 - 250 251 - 500 501 - 1,000 1,001 - 2,000 2,001 - 4,000 4,001 - 6,000 6,001 - 8,000 8,001 - 10,000 Over 10,000
Number of Installations (under the tracks):
Description of the Work to be Performed:
Does the project involve any work within 50 feet of the railroad right of way?: Yes No
Description of the Work to be Performed Within 50 Feet of the Railroad Right of Way:
Contract Number or Name:
Project Location (be as detailed as possible – mile marker, cross road, etc.):
In which state is the project located?: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
In which city is the project located?: In which locality is the project located?: - - - Cities & Municipalities - - - Adairville Albany Alexandria Allen Anchorage Arlington Ashland Auburn Audubon Park Augusta Bancroft Barbourmeade Barbourville Bardwell Barlow Beattyville Beaver Dam Bedford Beechwood Village Bellemeade Bellevue Bellewood Benton Berea Berry Blue Ridge Manor Bowling Green Bradfordsville Brandenburg Briarwood Brodhead Broeck Pointe Bromley Brooksville Brownsboro Farm Brownsboro Village Brownsville Burgin Burkesville Burnside Butler Cadiz Calhoun California Calvert City Cambridge Campbellsburg Campbellsville Campton Caneyville Carlisle Carrollton Catlettsburg Cave City Centertown Central City Clarkson Clay Clay City Cloverport Coal Run Village Cold Spring Coldstream Columbia Corbin Corinth Corydon Covington Crab Orchard Creekside Crescent Springs Crestview Crestwood Crittenden Crofton Crossgate Cumberland Cynthiana Danville Dawson Springs Dayton Dixon Douglass Hills Dover Druid Hills Dry Ridge Earlington Eddyville Edmonton Ekron Elizabethtown Elkhorn City Elkton Elsmere Eminence Erlanger Evarts Ewing Falmouth Fincastle Flatwoods Fleming-Neon Flemingsburg Florence Fordsville Forest Hills Fort Mitchell Fort Thomas Fort Wright Fountain Run Fox Chase Frankfort Franklin Fredonia Frenchburg Gamaliel Georgetown Ghent Glasgow Glencoe Glenview Glenview Hills Glenview Manor Goose Creek Goshen Graymoor-Devondale Grayson Green Spring Greensburg Greenup Greenville Guthrie Hanson Hardinsburg Harlan Harrodsburg Hartford Hawesville Hazard Hebron Estates Henderson Heritage Creek Hickman Hickory Hill Highland Heights Hills And Dales Hillview Hindman Hodgenville Hollow Creek Hopkinsville Horse Cave Houston Acres Hunters Hollow Hurstbourne Hurstbourne Acres Hustonville Hyden Indian Hills Irvine Irvington Island Jackson Jamestown Jeffersontown Jeffersonville Jenkins Junction City Kingsley Kuttawa La Center Lafayette Lagrange Lakeside Park Lancaster Langdon Place Lawrenceburg Lebanon Lebanon Junction Leitchfield Lewisburg Lexington-Fayette Liberty Lincolnshire Livermore Livingston London Loretto Louisa Louisville Urban Services Dist Louisville-Jefferson Loyall Ludlow Lyndon Lynnview Madisonville Manchester Manor Creek Marion Martin Maryhill Estates Mayfield Maysville McHenry McKee Meadow Vale Meadowbrook Farm Meadowview Estates Melbourne Mentor Middlesboro Middletown Midway Millersburg Milton Mockingbird Valley Monticello Morehead Morganfield Morgantown Mortons Gap Mount Sterling Mount Vernon Mount Washington Muldraugh Munfordville Murray Murray Hill Nebo New Castle New Haven Newport Nicholasville Norbourne Estates North Middletown Northfield Nortonville Norwood Oak Grove Oakland Old Brownsboro Place Olive Hill Orchard Grass Hills Owensboro Owingsville Paducah Paintsville Paris Park City Park Hills Parkway Village Pembroke Perryville Pewee Valley Pineville Pioneer Village Plantation Pleasureville Plum Springs Powderly Prestonsburg Prestonville Princeton Prospect Providence Raceland Radcliff Ravenna Richlawn Richmond River Bluff Riverwood Robards Rockport Rolling Fields Rolling Hills Russell Springs Russellville Ryland Heights Sacramento Sadieville Salyersville Sandy Hook Science Hill Scottsville Sebree Seneca Gardens Shelbyville Shepherdsville Shively Silver Grove Simpsonville Slaughters Smithfield Smithland Smiths Grove Somerset South Shore Southgate Sparta Spring Valley Springfield St. Charles St. Matthews St. Regis Park Stamping Ground Stanford Stanton Strathmoor Manor Strathmoor Village Sturgis Sycamore Taylor Mill Taylorsville Ten Broeck Thornhill Tompkinsville Trenton Uniontown Vanceburg Versailles Vicco Villa Hills Vine Grove Walton Warsaw Watterson Park Wayland Wellington West Buechel West Liberty West Point Westwood Wheatcroft Wheelwright White Plains Whitesburg Whitesville Wickliffe Wilder Wildwood Williamsburg Williamstown Wilmore Winchester Windy Hills Wingo Woodburn Woodbury Woodland Hills Woodlawn Woodlawn Park Worthington Worthington Hills Worthville Wurtland - - - - - - - Counties - - - - - - - Anderson County Bell County Breckinridge County Bullitt County Campbell County Carter County Casey County Clark County Crittenden County Daviess County Elliott County Fleming County Franklin County Fulton County Garrard County Henderson County Hopkins County Jackson County Kenton County Lewis County Lexington-Fayette County Mason County McCracken County McCreary County Meade County Menifee County Morgan County Oldham County Owen County Owsley County Powell County Pulaski County Rockcastle County Spencer County Todd County Trigg County Washington County Wayne County
"The work is:"  (Check ALL that apply. You must check at least one item.) adjacent to the tracks over the tracks under the tracks at right angles to the tracks parallel to the tracks
"The project or work involves:"  (Check ALL that apply) Use of explosives or fireworks Underground construction such as subways or mines (does not apply to underground pipe) Work in existing refineries, chemical plants, mills or grain elevators Hazardous chemicals Underwater Actual construction of tracks while any trains pass through the right of way
Total Contract Price:
Contract Price Within 50 Feet of the Railroad Right of Way:
Of the contract price within 50 feet of the railroad right of way, how much is for materials?
# Trains Per Day:   0 1 - 5 6 - 20 21 - 40 41 - 60 61 - 100 Over 100
Requested Limits:	Your General Liability and Umbrella policy information: Limit carried must equal or be greater than limit requested 1mm/3mm 2mm/6mm 5mm/10mm 10mm/10mm 10mm/20mm Other (Format as XXmm/YYmm. Example: 7mm/12mm)
Contractor Information
Contractor Company:
Company Address:	CityStateZip
General Liability Ins. Co.:		Limits of Liability: 1mm/1mm 1mm/2mm 2mm/4mm
Effective Date:    (mm/dd/yyyy format) Expiration Date:    (mm/dd/yyyy format)
Umbrella Liability Ins. Co.:		Umbrella Limit of Liability:   1,000,000 2,000,000 3,000,000 4,000,000 5,000,000 Greater than 5,000,000
Will a project contract, including a hold harmless agreement, be signed by the designated contractor?: Yes No
Will the railroad be named as an additional insured on the contractor’s GL policy?: Yes No
Will the contractual exclusion for the work within 50 feet of the railroad property be deleted on the contractor’s general liability and umbrella policies?: Yes No
Is a Slow Order in place for the duration of the project?: Yes No
Will the railroad assign flagmen or supervisors to the project?: Yes No
Will other railroad employees (other than flagmen/supervisors) be assigned to the project? Yes No
Please explain (regarding your YES answer to the above question):
Comments:

Retrieve Policy

To All Prospective Insureds: Any person who knowingly, and with intent to defraud any insurance company or other person, files an application for insurance or statement of claim containing any materially false information, or, for the purpose of misleading, conceals information concerning any fact material thereto, may commit a fraudulent insurance act which is a crime and subjects such person to criminal and civil penalties in many states.

To Prospective Insureds In:

Notice to Colorado Applicants: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claiming with regard to a settlement or award payable for insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

Notice to District of Columbia and Louisiana Applicants: “Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.”

Notice to Florida and Oklahoma Applicants: Any person who knowingly and with intent to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading information is guilty of a felony of the third degree. (Note: In Oklahoma the language must appear on the face of the policy in 10 pt. font or larger).

Notice to Kansas Applicants: An act committed by any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto.

Notice to Maine, Tennessee, Virginia and Washington Applications: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines and/or denial of insurance benefits.

Notice to Maryland Applicants: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Notice to New Hampshire Applicants: Any person who, with a purpose to injure, defraud or deceive an insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud as provided in RSA 638:20.

Notice to New York Applicants: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim 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, and shall also be subject to a civil penalty not to exceed $5,000 and the stated value of the claim for each such violation.

Notice to New York Applicants (Fire insurance applications): Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime. The proposed insured affirms that the foregoing information is true and agrees that these applications shall constitute a part of any policy issued whether attached or not and that any willful concealment or misrepresentation of a material fact or circumstances shall be grounds to rescind the insurance policy.

Notice to New York Applicants (Automobile): Any person who knowingly makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, damage or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or an insurance company, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed $5,000 and the value of the subject motor vehicle or stated claim for each violation."

Notice to Pennsylvania Applicants: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for purposes of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

Notice to Pennsylvania Applicants (Automobile): Any person who knowingly and with intent to injure or defraud any insurer files an application or claim containing any false, incomplete or misleading information, shall, upon conviction, be subject to imprisonment for up to seven (7) years and the payment of a fine of up to $15,000.