Fillable KINSALE Welding Supplemental Application

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KINSALE Welding Supplemental Application

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The KINSALE Welding Supplemental Application form is 5 pages long and contains:

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  • 50 check-boxes
  • 112 other fields

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Page 1 of 5
WELDING OPERATIONS SUPPLEMENTAL APPLICATION
COMPLETE IN ADDITION TO ACORD APPLICATIONS.
ATTACH ADDITIONAL SHEETS AS NECESSARY.
ANSWER ALL QUESTIONS. If not applicable, indicate N/A.
DATE:
APPLICANT’S NAME:
MAILING ADDRESS:
STREET ADDRESS (if different):
CITY, STATE, ZIP CODE:
BUSINESS LOCATION ADDRESS:
1) Has applicant had previous insurance for this enterprise? Yes No
If yes, provide the following information:
Insurance company Policy period Limits of insurance Premium Occurrence or
claims made
2) Is applicant engaged in, owned by, associated with or involved in any other enterprise? Yes No
(Please provide full details.)
3) Provide details of licenses and certifications held:
4) During the past (3) three years, have any claims been presented to any current or prior Yes No
insurance carrier? (If yes, provide details including description of claim.)
APPLICANT’S INFORMATION
GENERAL INFORMATION
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 5
5) Is the applicant, or any other person for whom insurance is being requested, aware of any Yes No
circumstance which may result in a claim? (If yes, give full details.)
6) Has applicant, or any other person for whom coverage is being requested, had any liability Yes No
application denied, policy cancelled or policy not renewed in past (3) three years? (If yes, give
full details.)
7) Has the applicant, or any other person for whom coverage is being requested, ever been fined, Yes No
or cited for performing unsafe work? (If yes, give full details.)
8) How many years of experience have you had in the welding business? years
9) Do you have standard contract that you use for all projects and work? Yes No
(If yes, please furnish a copy.)
10) What type of welding/brazing/soldering processes are performed? Provide percentage of total operations for each
type performed:
Type of process % Type of process %
Brazing
Laser beam welding
Arc welding
Resistance welding
Gas welding
Soldering
Electron beam welding
Solid state welding
Electro slag welding
Thermite welding
Induction welding
Other (describe below)
Describe “other” process:
11) Percentage of operations performed: In shop % Off site/mobile %
a) Total number of employees performing welding / brazing duties.
b) Number of employees certified only by American Welding Society
c) Number of employees certified only by American Society of Mechanical Engineers
d) Number of employees that are not certified by either of the above
e) If work is performed by non-certified person, is work inspected and approved Yes No
by a certified welder?
12) Work performed is: __________% Residential __________% Commercial __________% Industrial
13) Does your company specialize in a certain industry or certain type of welding? Yes No
If Yes, describe:
Page 3 of 5
14) Off Site/Mobile operations:
Are fire extinguishers and first aid kit taken to each job site? Yes No
Describe site preparation procedures taken to prevent fire losses or injury to others:
15) Indicate percentage of welding work, if any, done on the following. Provide percentage of annual receipts for each
type of work.
Type of Work % Type of Work %
Aircraft/Aerospace Metal Erection:
Aluminum Containers Decorative or Artistic
Automobile/Truck/Bus: Nonstructural
Accessories, bins, racks Standpipes, water towers, silos
Bumpers, trailer hitches Balconies, handrails or stairway
Frame and/or Axle work Off shore work*
Roll bars or safety cages Oil field work*
Other* (Describe below) Oil field work-over the hole
Boilers Pipeline/Process Piping:
Bridges Chemical (Non-Petrochem)
Gas (LPG, Natural, etc.)
Building Construction (Structural): Food/Beverage Processing
One or Two Story
Gasoline/Oil
Three to Five Story Water
Over Five Story Other * (Describe below)
Contractors Equipment* Pressure Vessels (not tanks)
Conveyor Systems Railroad Tracks
Cutting of scrap for salvage or recycling Railroad Cars
Elevators or Feed Mills Refinery, chemical or petrochemical work
Farm Equipment* Security Doors
Fence/Gate Shipbuilding
Forklift/Lift truck Repair Tanks:
Furniture Pressurized
Guardrail Erection/Repair Non-pressurized
Logging Equipment Window Bars/Guards
Industrial Machinery/Equipment* Other* (Describe below)
Describe “other” work and explain in detail any operation indicated by * above.
16) Any work done on existing oil or gas Lines? Yes No
If Yes, are all lines purged and flushed prior to welding? Yes No
Are the lines ever pressurized during the work process? Yes No
17) Does the applicant rent welding equipment or supplies to others? Yes No
If Yes, annual receipts: $ ____________________
18) Does the applicant repair welding equipment for others? Yes No
If Yes, are you factory authorized for such repairs? Yes No
Page 4 of 5
19) Does the applicant offer rental, sales, service or filling or refilling of gas cylinders? Yes No
If Yes, annual receipts: $ ____________________
20) Does the applicant build or manufacture a finished product? Yes No
If Yes, describe type of products manufactured.
1) Does the applicant use a standard client contract, which outlines the specific Yes No
responsibilities of the applicant? (Attach copy.)
2) Do others hold applicant harmless? Yes No
3) Does applicant agree to hold any third party harmless? Yes No
4) Does applicant assume, by contract or verbally, responsibility for any injury or damage Yes No
or damage that may occur?
5) Does applicant have Workers’ Compensation coverage in force? Yes No
6) Does applicant lease employees? Yes No
7) Does the applicant have a website? Yes No
If Yes, provide website address:
FRAUD WARNING
NOTICE TO ALABAMA, ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, CONNECTICUT, DELAWARE, GEORGIA, IDAHO, ILLINOIS, INDIANA, IOWA, KANSAS,
MARYLAND, MASSACHUSETTS, MICHIGAN, MINNESOTA, MISSISSIPPI, MISSOURI, MONTANA, NEBRASKA, NEVADA, NEW HAMPSHIRE, NORTH CAROLINA,
NORTH DAKOTA, OREGON, RHODE ISLAND, SOUTH CAROLINA, SOUTH DAKOTA, TEXAS, UTAH, VERMONT, WASHINGTON, WEST VIRGINIA, WISCONSIN,
AND WYOMING APPLICANTS: In some states, 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 in many states.
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 policy holder 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 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 insurance company files a statement of
claim containing any false, incomplete or misleading information is guilty of a felony of the third degree.
NOTICE TO HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or
benefit is a crime punishable by fines or imprisonment, or both.
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.
HOLD HARMLESS AGREEMENTS
Page 5 of 5
NOTICE TO 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 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 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 MEXICO 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 civil fines and criminal penalties.
NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud an 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 OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he/she 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 a any claim
for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
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 a 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 the person to criminal and civil penalties.
NOTICE TO TENNESSEE 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 VIRGINIA 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.
The Applicant acknowledges that the answers provided herein are based on a reasonable inquiry and/or investigation. The Applicant warrants that the
above statements and particulars together with any attached or appended documents are true and complete and do not misrepresent, misstate or omit
any material facts. The Applicant agrees to notify us of any material changes in the answers to the questions on this questionnaire which may arise prior
to the effective date of any policy issued pursuant to this questionnaire and the Applicant understands that any outstanding quotations may be modified
or withdrawn based upon such changes at our sole discretion.
Completion of this form does not bind coverage. Applicant’s acceptance of the company’s quotation is required prior to binding coverage and policy
issuance. All written statements and materials furnished to the company in conjunction with this application are hereby incorporated by reference into
this application and made a part of this application.
Applicant:
Title:
FEIN #:
Applicant’s Signature: Date:
Agent/Broker Name:
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KINSALE Welding Supplemental Application

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Completed 2 July 2020

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