Railroad Passenger Car Alliance

2022 LIABILITY
INSURANCE APPLICATION

INSURED INFORMATION 2022
INSURED NAME EFFECTIVE DATE AGENT
CONTACT NAME
CONTACT EMAIL
PHONE #1 PHONE #2 FAX
MAILING ADDRESS
CITY STATE ZIP
ANY LOSSES IN THE PAST 5 YEARS? YES NO
 
RAILCAR SCHEDULE ( more than 8 Railcars require underwriter approval )
TYPE Description ( Year, Manfacturer, Model, Road Name REPORTING MARK
#1
Storage Address (Street, City, State, ZIP)
#2
Storage Address (Street, City, State, ZIP)
#3
Storage Address (Street, City, State, ZIP)
#4
Storage Address (Street, City, State, ZIP)
#5
Storage Address (Street, City, State, ZIP)
#6
Storage Address (Street, City, State, ZIP)
#7
Storage Address (Street, City, State, ZIP)
#8
Storage Address (Street, City, State, ZIP)
PREMIUM CALCULATION
Please read instructions carefully for premium rating:
1.) Enter the TOTAL annual moves of ALL railcars to be insured.
2.) Enter the number of railcars to be insured.
3.) Select the requested Limits of Liability
4.) If applicable, enter the # of static locomotives. *See below

5.) CLICK THE REFRESH PREMIUM BUTTON


6.) Type your full name at the bottom and CLICK SUBMIT


*STATIC LOCOMOTIVES are eligible for coverage on this form. They are rated individually based on the FIRST CAR RATE. Quantity must be entered in #3 and should not be included in the TOTAL # of RAILCARS entered in #2
Please Enter the Following Information:
1 TOTAL ANNUAL MOVES FOR ALL RAILCARS
2 TOTAL # OF RAILCARS TO BE INSURED
3 # OF STATIC LOCOMOTIVES
Premium Rating Factors
4
Liability Limits      United Shortline       United Shortline       United Shortline       United Shortline       United Shortline    
5 AVERAGE # OF MOVES PER RAILCAR
6 *See Premium Reference Chart RATE FOR FIRST CAR $ 0.00
7 *See Premium Reference Chart RATE FOR EACH Add’l CAR $ 0.00
SUB-TOTAL PREMIUM $0.00
Variable Rating Factors
Optional Static Locomotive $ 0.00
2.25% Surplus Lines Tax $ 0.00
TOTAL PREMIUM DUE $0.00
Liability Limits Premium Reference (occurence / aggregate in $ millions)
Average moves per railcar 1m/2m 2m/4m 3m/6m 4m/8m 5m/10m
1$575.00$1,065.00$1,360.00$1,630.00$1,910.00
2$575.00$1,065.00$1,360.00$1,630.00$1,910.00
3$575.00$1,065.00$1,360.00$1,630.00$1,910.00
4$1,000.00$1,890.00$2,210.00$2,625.00$3,040.00
5$1,000.00$1,890.00$2,210.00$2,625.00$3,040.00
6$1,000.00$1,890.00$2,210.00$2,625.00$3,040.00
7$1,000.00$1,890.00$2,210.00$2,625.00$3,040.00
8+$1,455.00$2,750.00$3,100.00$3,695.00$4,295.00
Add'l Railcar(s)$495.00$560.00$625.00$690.00$760.00
Certificate Holders
CERT HOLDER #1 Name: Account #
Mailing Address
(Street, City, State, ZIP)
Email: Please Select Addl Insured Waiver of Subrogation
CERT HOLDER #2 Name: Account #
Mailing Address
(Street, City, State, ZIP)
Email: Please Select Addl Insured Waiver of Subrogation
CERT HOLDER #3 Name: Account #
Mailing Address
(Street, City, State, ZIP)
Email: Please Select Addl Insured Waiver of Subrogation
CERT HOLDER #4 Name: Account #
Mailing Address
(Street, City, State, ZIP)
Email: Please Select Addl Insured Waiver of Subrogation
CERT HOLDER #5 Name: Account #
Mailing Address
(Street, City, State, ZIP)
Email: Please Select Addl Insured Waiver of Subrogation
TOTAL PREMIUM DUE $0.00

If you are ready to submit this form, type your name in the box below then click SUBMIT
Please Note: Coverage cannot be bound until the completed application and rating are approved by the underwriter. Full payment must accompany the application. You must be a member of RPCA to participate in the insurance program. RPCA membership certificate is required. No refunds on premiums paid if insured cancels policy.