RPL Program Application
  1. Are you:


    Invalid Input
    Please tell us if you are an agency or a contractor who will be working on the project.
  2.  
  1. Agency Information
  2. Page 2 of 5
  3. Applicant Name:
    Invalid Input
    Name of person completing the application.
  4. Applicant Phone Number:
    Please format the phone number without any dashes or spaces.
    Please supply a phone number without Dashes (-) where we can reach the you.
  5. Applicant E-Mail Address:
    Please supply a valid E-Mail Address
    Please supply a valid E-Mail address where we can reach the you.
  6. Page 2 of 5
  7.  
  1. Contractor's Information
  2. Page 3 of 5
  3. Name:
    Please supply the name of the Contractor Performing the Work.
  4. Mailing Address:
    Please supply a valid address for the contractor performing the work where we can send documents and other information.
  5. City:
    Invalid Input
    Please supply the name of the city where the contractor is based.
  6. State:
    Please select a State.
    Please select the state where the contractor is located.
  7. Zip Code:
    Please supply a valid zip code.
    Please supply the zip code of where the contractor is located.
  8. Phone Number:
    Please supply a valid phone number with no spaces or dashes.
    Please supply a valid phone number where we can contact the contractor.
  9. Fax:
    Please supply a valid fax number without dashes or spaces.
    Please supply a valid fax number that we can use to fax documents to the contractor.
  10. E-Mail Address:
    Please supply a valid E-Mail address.
    Please supply a valid E-Mail address where we can contact the contractor.
    12. General Liability Insurance
  13. Carrier:
    Invalid Input
    Please supply the name of the contractor's insurance carrier.
  14. Occurrence/Aggregate:
    Invalid Input
    Please supply the occurrence/aggregate rate of the contractor's general liability insurance.
  15. Renewal Date:

    Invalid Input
    Please supply the renewal date of the general liability insurance.
  16. Policy Number:
    Please supply a valid general liability insurance policy number.
    Please supply a valid general liability insurance policy number for the contractor.
    18. Excess/Umbrella Insurance
  19. Carrier:
    Invalid Input
    Please supply the name of the insurance provider that provides excess/umbrella insurance to the contractor.
  20. Occurrence/Aggregate:
    Invalid Input
    Please supply the Occurrence/Aggregate rate of the excess/umbrella insurance.
  21. Renewal Date:

    Invalid Input
    Please supply the renewal date of the excess/umbrella insurance.
  22. Policy Number:
    Please supply a valid policy number.
    Please supply the contractor's insurance policy number for excess/umbrella insurance.
  25. Will the Railroad be an additional insured on the Contractor's GL Policy?:
    Invalid Input
  26. Will the contractual exclusion for work within 50 feet of Railroad be deleted on Contractor's GL and Umbrella Policies?:
    Please well us of the contractual exclusion for work within 50 feet of a railroad be deleted from the contractor's general liability and umbrella insurance policies.
  27. Does the Contractor hold the RR harmless for this project?:
    Invalid Input
  28. Page 3 of 5
  29.  
  1. Project Information
  2. Page 4 of 5
  3. Governmental Authority or Owner Name:
    Invalid Input
    Name of the Governmental Authority or Owner for whom the work is being performed, if applicable:
  4. Address:
    Invalid Input
    Address of the Governmental Authority or Owner for the work being performed, if applicable.
  5. City:
    Invalid Input
    City in which the Governmental Authority or Owner of work being performed resides, if applicable.
  6. State:
    Invalid Input
    Please select the State in which the Governmental Authority or Owner whom the work being performed resides, if applicable.
  7. Zip Code:
    Invalid Input
    Please supply the zip code of where the Governmental Authority or Owner for whom the work is being performed resides, if applicable.
    9. Anticipated Project Details:
  10. Bid Date:
    Invalid Input
    Please supply the date the project is due to bid.
  11. Start Date:

    Invalid Input
    Please supply the anticipated start date for the project.
  12. Finish Date:

    Invalid Input
    Please supply the anticipated completion date of the project.
    14. Job Location
  15. Nearest Mile Marker:
    Invalid Input
    Please provide the nearest mile marker closest to the job site.
  16. Nearest City:
    Invalid Input
    Please supply the city or town nearest to the location of the job site.
  17. State:
    Invalid Input
    Please select the state in which the project will take place.
  20. Project Number
    Invalid Input
    Please supply the job's contract or project number.
  21. Complete Description of Job:
    Invalid Input
    Please supply a detailed description of the job.
  22. Job Description Within 50 ft of Railroad Right-of-Way:
    Invalid Input
    Please supply a complete description of the part of the job that will take place within 50 feet of the Railroad Right-of-way
  23. Will the work involve:






    Invalid Input
    Please indicate any type of work that will be completed during the job. Select all that apply.
  24. Please Describe:
    Invalid Input
    Please describe each of the selections you made above with details about each specific selection.
  25. Page 4 of 5
  26.  
  1. Railroad Information
  2. Page 5 of 5
  3. Name of Railroad:
    Please select the railroad the where the work is being done. If the railroad is not listed select '**Railroad not listed**'
    5. Unlisted Railroad Information
  6. Name:
    Invalid Input
    Name of Railroad (if unlisted)
  7. Address:
    Invalid Input
    Please supply an address where we may contact the unlisted railroad.
  8. City:
    Invalid Input
    Please supply the city where the supplied address for the railroad is located.
  9. State:
    Invalid Input
    Please select a state where the supplied address for the railroad is located.
  10. Zip Code:
    Invalid Input
    Please supply the zip code of the supplied address for the railroad.
    14. RPL Standard Limits Requested:
  15. Invalid Input
    Please supply the RPL standard limits requested.
    19. Railroad Permit Contact Info:
  20. Contact Name:
    Invalid Input
    Please supply the contact name on the railroad's permit.
  21. Contact E-Mail:
    Invalid Input
    Please supply an E-Mail address where the contact for the railroad permit can be reached.
  22. Contact Phone:
    Please supply a valid phone number without spaces or dashes.
    Please supply a valid phone number where the railroad contact may be reached.
    26. Number of Daily
  27. Trains:
    Invalid Input
    Please supply the number of daily trains that use the railroad at the job location.
  28. Passengers:
    Invalid Input
    Please supply the daily number of passengers that are on the railroad at the job location.
  29. Freight:
    Invalid Input
    Please supply the amount of freight/day transported on the railroad past the location where job is being performed.
  30. Slow Order:
    Invalid Input
    Please select (Yes or No) if the railroad uses a Slow Order.
  31. Flagmen/Supervisors:
    Invalid Input
    Please select (Yes or No) if Flagmen or Supervisors will be present.
  32. Are Other Railroad Employees Assigned to This Project?:
    Invalid Input
    Please indicate (Yes or No) if other railroad employees will be assigned to this project.
  33. What kind of work will they perform?
    Invalid Input
    If yes, please list the number of employees and what kind of work each will be performing.
  36. Any Additional Comments or Project Information:
    Invalid Input
    If you have any additional information about the project that was not answered in another part of the form, please supply it here.
  37. Total Project Value
    Invalid Input
    Please select the range in which the total project value falls.
  38. Project Value within Right-of-Way
    Invalid Input
    Please tell us how valuable to the project is within 50 feet of the Railroad.
    40. Pricing Information
  41. Project Type
    Invalid Input
    Please select the type of project.
  42. Project Description:
    Invalid Input
    Please select a description of the Wire/Pipe Installation.
  43. Project Description
    Invalid Input
    Please select a description of the construction work being performed.
  44. Project Details:
    Invalid Input
    Please tell us where the Wire/Pipe is being installed (Overhead/Underground) and the number of feet.
  45. Project Details:
    Invalid Input
    Please select whether the wire or pipe is being located underground or overhead.
  48. Page 5 of 5
  50. Terms and Conditions(*)
    You must agree to the terms and conditions.
    You must agree to our terms and conditions to continue.

RPL Quote

Get a Quote Today!

rplapplicationbutton

Customer Login

Have a Previous Quote Form Already Completed? Sign in here to retrieve it.

Contact Us

255 NW Blue Parkway
Suite 102
PO Box 1540
Lee's Summit, MO 64063

Phone: (877) 551-1677

Fax: (888) 972-7831

contact

Make A Payment

makeapayment