Welders and Field Services Application

General Information:

Name:

Doing Business As (DBA):

Entity Type:

Location Address:

City:

State:

ZIP:

Mailing Address:

City:

State:

ZIP:

Phone:

Email:

List States Where You Primarily Work:

Detailed Description of Operations:

Number of Part-Time Employees:

Number of Full-Time Employees:

Total Employee Payroll:

Owner Payroll:

Annual Gross Sales (Estimate if new in business):

Requested Effective Date:

Web Address:

How did you hear about us?

Please specify

Underwriting Information:

1.) GL Limits Requested:

$500,000/$1,000,000

$1,000,000/$2,000,000

2.) Are you new in business?

Yes

No

Number of Years in Business:

3.) Are fire extinguishers taken to each job site?

Yes

No

Please Explain:

4.) Does your work take place off premises?

Yes

No

Please Explain:

5.) Have you been cancelled or non-renewed for any reason by a prior carrier?

Yes

No

Please Explain:

6.) Any bankruptcies, tax, credit, or other liens against you in the past 5 years?

Yes

No

Please Explain:

7.) Do you build or manufacture a finished product of any kind?

Yes

No

Please Explain:

8.) Are you licensed?

Yes

No

What kind of license?

Describe experience and training:

9.) Are your employees certified?

Yes

No

10.) For what types of customer do you primarily weld? (Indicate Percentage total = 100%)

Industrial - Residential - Commercial - Agricultural

11.) Do you work on any of the following?

a. Live natural gas lines?

Yes

No

Provide additional details:

Describe operations related to Live natural gas lines. Such as, how often and what percentage of your overall work.

b. Work within refineries?

Yes

No

Provide additional details:

Describe operations related to work within refineries. Such as, how often and what percentage of your overall work.

c. Drilling Derricks?

Yes

No

Provide additional details:

Describe operations related to drilling derricks. Such as, how often and what percentage of your overall work.

d. Over-the-hole?

Yes

No

Provide additional details:

Describe operations related to over-the-hole. Such as, how often and what percentage of your overall work.

e. Operating crude or paraffin oil lines?

Yes

No

Provide additional details:

Describe operations related to operating crude or paraffin oil lines. Such as, how often and what percentage of your overall work.

f. Any existing (not new construction) oil or gas lines?

Yes

No

Provide additional details:

Describe operations related to any existing oil or gas lines. Such as, how often and what percentage of your overall work.

g. In or around grain (bins, silos, elevators, etc.)?

Yes

No

Provide additional details:

Describe operations related to grain bins, silos, elevators, etc. Such as, how often and what percentage of your overall work.

h. Any structural welding over 4 stories or any bridge construction?

Yes

No

Provide additional details:

Describe operations related to structural welding over 4 stories, or any bridge construction. Such as, how often and what percentage of your overall work.

i. Aircraft or aerospace?

Yes

No

Provide additional details:

Describe operations related to aircraft or aerospace. Such as, how often and what percentage of your overall work.

j. Pressure vessels (i.e. boilers, tanks)?

Yes

No

Provide additional details:

Describe operations related to pressure vessels. Such as, how often and what percentage of your overall work.

k. Farm equipment?

Yes

No

Payroll: (Including Owner)

Only include payroll for this operation.

12.) What type of welding/brazing/soldering process are performed?

Provide percentage of total operations for each type performed, equaling 100%.

a. Brazing:

Arc Welding:

Gas Welding:

Electron Beam Welding:

Electro Slag Welding:

Introduction Welding:

Laser Beam Welding:

Resistance Welding:

Soldering:

Solid State Welding:

Thermite Welding:

Other:

Describe other process and percentage.

13.) Percentage of operations performed:

Total of "In Shop" and Off site/Mobile" should equal 100%.

a. In Shop:

b. Off Site/Mobile:

.

14.) Indicate percentage of welding work, if any, done on the following:

Provide percentage of annual receipts for each type of work. All percentages combined should equal 100%.

Aircraft/Aerospace:

Aluminum Containers:

(+) Automobile/truck/bus:

Boilers:

Bridges

(+) Building construction (structural):

(+) Contractors Equipment:

Conveyor systems:

Cutting of scrap for salvage or recycling:

Elevators or Feed Mills:

(+) Farm Equipment:

Fence/Gate:

Forklift/Lift Truck Repair:

Furniture:

Guardrail Erection/Repair:

Logging Equipment:

(+) Industrial Machinery/Equipment:

(+) Metal Erection:

(+) Off Shore Work:

(+) Oil Field Work:

Oil Field Work - Over the Hole:

(+) Pipeline/Process Piping:

Pressure Vessels (not tanks):

Railroad Tracks:

Railroad Cars:

Refinery, Chemical or Petrochemical:

Security Doors:

Shipbuilding:

(+) Tanks:

Window Bars/Guards:

Other (describe and put %):

Explain In Detail Any Operation Indicated By (+) Above:

15.) Any work done on existing oil or gas lines?

Yes

No

a. Are all lines purged and flushed prior to welding?

Yes

No

b. Are the lines ever pressurized during the work process?

Yes

No

16.) Do you rent welding equipment or supplies to others?

Yes

No

a. Annual Receipts:

17.) Do you repair welding equipment for others?

Yes

No

a. Are you factory authorized for such repairs?

Yes

No

18.) Do you offer rental, sales, service or filling or refilling of gas cylinders?

Yes

No

Annual Receipts:

Prior Carrier Premium and Loss History:

Loss History:

Available Coverages:

Vehicle Mounted Equipment:

Vehicle Mounted Equipment:

Total Limit:

Your Unscheduled Tools and Equipment:

Blanket coverage on small tools and equipment.

Limit Any One Item:

Total Limit:

Materials, Parts and Supplies:

Blanket coverage on expendable materials, parts, and supplies used in your business operations, but only while they are located in or on a described "Service Vehicle."

Limit Any One Item:

Total Limit:

Bailee's Liability Extension:

Covers your legal liability for property of others in your care, custody, control while it is being worked on in the field, but it does not include coverage on such property at your own location(s).

Limit In Any One "Temporary Job Location":

Limit In Transit:

Total Limit:

Notice:

NOTICE OF INSURANCE INFORMATION PRACTICES. In connection with this application for insurance ( and subsequent policy renewals), your personal information may be collected from persons other than you and without your authorization (e.g., credit reports). You have the right to preview your personal information in our files and may request correction of any inaccuracies contained therein. A more detailed description of your rights and our practices regarding such information will be available upon request and you may contact your agent or broker for instructions regarding how to submit this request to us.

Any person who knowingly files an application for insurance or a statement of claim with materially false information with the intent to defraud an insurance company or other person is committing a fraudulent insurance act. Moreover, any person who has concealed material facts for the purpose of providing misleading information is also committing a fraudulent insurance act. These acts are crimes and subjects the person to criminal and [NY:substantial] civil penalties. (Not applicable in CO, FL, HI, MA, NE, OH, OR, or VT; in DC, LA, ME, TN, VA and WA insurance benefits may also be denied). IN Florida, it is a third degree felony to knowingly file a statement of claim or any application containing false, incomplete, or misleading information with the intent to injure, defraud, and/or deceive any insurer.

The undersigned is an authorized representative of the applicant and acknowledges that reasonably inquiry has been made to obtain the information on this application. He/she acknowledges that the answers are true, correct and complete to the best of his/her knowledge.

Applicant Signature:

Printed Name:

Title:

Date: