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GENERAL INFORMATION www .cfins.c om E ff ectiv (Crum & Forster Insurance)

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GENERAL INFORMATION
www
.cfins.c
om
1. Applicant Name:
E
ff
ectiv
e Date:
2. List each Named Insured, the date started/acquired and description of operations:
Name:
Date started/acquired:
Opera
tions:
Name:
Date started/acquired:
Opera
tions:
Name:
Date started/acquired:
Opera
tions:
(Ownership breakdown will be requested if more than one requested Name Insured)
3. Has there been a change in management in the past 5 years? If so, please explain.
4. Please list all industry associa
tions
of which you are a member.
5. Please provide a narrative description of all your current operations:
6. Do you have any past, or discontinued operations, not described above? Yes No
If yes, please describe:
Page 2
Page 1
AUTOMOBILE AND DRIVER
/E&KZDd/KE
www
.cfins.c
om
1. What is your annual employee turnover ratio?
% Drivers
% Others
Applicant employs persons, as follows:
Tractor/Trailer Drivers
Cylinder Delivery Drivers
Maintenance
Outside Sales
Plant Mgrs.
Mechanics
Servicemen
Clerical
Other (describe)
2. What are your requirements for hiring drivers (experience,
writt
en / road tes
ting
, etc.):
3. Do you order and review MVRs prior to hiring all drivers? Yes No
What would disqualify a driver?
4. Do any drivers have: a DWI; more than 3 moving violations and/or accidents in the last 3 years; more than 2 moving
violations and/or accidents in the last 2 years? Yes No
If yes, please iden
tif
y on the driver list.
5. Do you have a drug/alcohol testing program? Yes No
If yes, describe your criteria for pass/fail (zero tolerance, proba
tion,
etc.)
6. Have any exceptions been made to your drug/alcohol policy? Yes No
If yes, provide details:
7. How are driver’s
activities
monitored?
8. Do you transport property of others? Yes No
If yes, advise c
ommodities
hauled, frequency and radius:
9. Do you have a written policy on personal use of company vehicles? Yes No
If yes, attach a copy.
10. Are employees, or your family members, allowed personal use of company vehicles? Yes No
If yes, describe who and under what c
onditions:
11. Do you rent or sales medical supplies? Yes No
If yes, describe what types of supplies:__________________________________________
12. Do your drivers travel throught major metro areas to make deliveries? Yes No
If yes, list metro areas: _______________________________________
Page
2
P%$G+'C*!"##$O
Page 3
1. Please provide a summary of sales/receipts (other than gases)
Type of good or services !8<13Q21I156?3
Hard goods
Fire Suppression Equipment (sales/installaon)
Fire Suppression Service (payroll)
Equipment Repair/Service (payroll)
Equipment rented to others
Medical Equipment (other than gases)
Other (describe)
Cylinder Rental
3. Please provide summary of gases distributed (sales)
C8313 R*E5<<1:*FJ*-?4123 R*E5<<1:*FJ*O;> R*&80>@8I?>21:*FJ*O;>
Acetylene
Ammonia
Argon
Carbon Dioxide
Compressed Air
Helium
Hydrogen
MAPP
Nitrogen
Nitrous Oxide
Oxygen
Propane
Propylene
Specialty Gases
Medical Oxygen
Medical Nitrous Oxide
Medical Ethylene
Various Mixes
Other (describe)
3. Do you manufacture acetylene?   Yes  No
If yes, then:
What type of manufacturing equipment is installed? _________________________________________________
What was the date this equipment was installed? ___________________________________________________
What date was the equipment last rebuilt? ________________________________________________________
Page 4
Describe distance to and occupancy of surrounding structures:
North distance occupancy
East distance occupancy
South distance occupancy
West distance occupancy
4. Please list all industrial gas bulk storage tanks.
Locaon C83*!?;21: ,868I5?J Locaon C83*!?;21: ,868I5?J
C%'%D)$*+'E-D&)(+-'
5. Do you sell any foreign manufactured products?   Yes  No
If yes, describe: ______________________________________________________________________________
6. Are these foreign manufactured products purchased from a U.S. Distributor?   Yes  No
7. Do you obtain hold harmless, waiver of subrogaon or addional insured status from your suppliers?   Yes  No
If yes, describe: ______________________________________________________________________________
8. Do you sell any product such as welding wire/rods/consumables that are repackaged, alter   Yes  No
the product or warning labels changed in any way?
If yes, describe: ______________________________________________________________________________
9. Do you sell any private label products?   Yes  No
10. Have you ever received a noce of injury, claim or suit from a third party regarding exposure/injury   Yes  No
to welding fume producing products?
If yes, describe: ______________________________________________________________________________
11. Do you control who equipment is rented to?   Yes  No
If yes, describe: ______________________________________________________________________________
12. Do you perform any producon welding?   Yes  No
13. Do you do any demonstraon welding or provide training?   Yes  No
14. Do you rent equipment, other than cylinders?   Yes  No
If yes, describe: ______________________________________________________________________________
15. Describe your record keeping for cylinders and gases sold: _______________________________________________
16. Do you sell medical gases?   Yes  No
If yes, describe your tesng/quality control procedures: _____________________________________________
Please
reference applicable questions
from
supplemental.
ADDITIONAL
SPACE
SUPPLEMENTAL
APPLICATION
www
.cfins.c
om
Page
5
Page 6
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 SUBJECTS THAT PERSON TO CRIMINAL AND CIVIL PENALTIES. (Not
applicable in AL, AR, CO, DC, FL, KS, KY, LA, MD, ME, NJ, NM, NY, OH, OK, OR, RI, TN, VA, VT, WA or WV - see Additional
Fraud Notices attached hereto for these States).
ADDITIONAL FRAUD NOTICES
NOTICE TO ALABAMA, ARKANSAS, LOUISIANA, NEW MEXICO, RHODE ISLAND AND WEST VIRGINIA 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 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 claimant with regard to a
settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of
Regulatory Agencies.
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING: It is a crime to provide false or misleading information to an insurer for the
purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance
benefits if false information materially related to a claim was provided by the applicant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim
or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
NOTICE TO KANSAS APPLICANTS: 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, electronic, electronic
impulse, facsimile, magnetic, oral, or telephonic communication or 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 commits a fraudulent insurance act.
NOTICE TO KENTUCKY APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance 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.
NOTICE TO MAINE APPLICANTS: 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 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 JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance
policy is subject to criminal and civil penalties.
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 five thousand dollars and the stated value of the claim for each such violation.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an
application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
NOTICE TO OKLAHOMA APPLICANTS: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes
any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
Page 7
NOTICE
TO OREGON APPLICANTS: Any person w
ho knowingly and with intent to defraud or solicit another to defraud the insurer by
submitting an application containing a false statement as to any material fact may be violating state law.
NOTICE TO TENNESSEE, VIRGINIA AND WASHINGTON APPLICANTS: It is a crime to knowingly provide false, incomplete, or misleading
information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance
benefits.
NOTICE TO VERMONT APPLICANTS: Any person who knowingly presents a false statement in an application for insurance may be guilty of a
criminal offense and subject to penalties under state law.
The undersigned declares that to the best of his or her knowledge and belief the statements and representations made
herein and in any attachments appended hereto and/or incorporated herein by reference are true and complete and that
no material facts have been misstated, misrepresented, suppressed or concealed. The signing of this application does not
bind the undersigned to purchase insurance, nor does review of the application bind any insurer to issue a policy. It is
agreed, however, that this application shall be the basis of the contract should a policy be issued. If there is any material
change in the answers to the questions provided herein or in any of the attachments appended hereto and/or
incorporated herein by reference prior to the effective date of the insurance policy, the applicant must immediately notify
the insurer in writing and the insurer reserves the right in such instance to modify or withdraw any quotation or binder
that may have been issued. The undersigned also represents and warrants that he or she is authorized on behalf of the
applicant to complete and sign this application on its behalf.
__________________________________________ ________________________________________
Applicant Name (Printed) Applicant Title
__________________________________________ ________________________________________
Applicant Signature* Date
* ELECTRONIC SIGNATURE AND ACCEPTANCE
☐
PRODUCER INFORMATION:
______________________________________________ ____________________________________________
Producer Name (Printed) Producer Signature*
______________________________________________ ___________________ ______________________
Agency Name Agency Code License Number
* ELECTRONIC SIGNATURE AND ACCEPTANCE
☐
* You can apply your signature to this form electronically by checking the Electronic Signature And Acceptance box below
your signature line and by then either applying your electronic signature to this form or by typing your name above your
signature line on this form. By doing so, you hereby consent and agree that your use of a key pad, mouse, keyboard or
other device to accomplish the foregoing constitutes your signature, acceptance, and agreement as if actually signed by
you in writing and has the same force and effect as a signature affixed by hand. Further, you agree that the lack of a
certification authority or other third party verification will not in any way affect the validity or enforceability of your
signature or any resulting contract.
The C&F logo, C&F, and Crum & Forster are registered trademarks of United States Fire Insurance Company. Crum & Forster is comprised of leading and well-established property and casualty business units and insurance
companies including United States Fire Insurance Company, The North River Insurance Company, Crum and Forster Insurance Company and Crum & Forster Indemnity Company.
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GENERAL INFORMATION www .cfins.c om E ff ectiv (Crum & Forster Insurance)

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Completed 13 July 2021

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