Fillable Welding, Brazing and Cutting General Liability Supplemental Application (RT Specialty)

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Welding, Brazing and Cutting General Liability Supplemental Application (RT Specialty)

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Scottsdale Insurance Company
Home Office: One Nationwide Plaza
Columbus, Ohio 43215
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
Scottsdale Indemnity Company
Home Office: One Nationwide Plaza
Columbus, Ohio 43215
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
Scottsdale Surplus Lines Insurance Company
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
1-800-423-7675 • Fax (480) 483-6752
www.scottsdaleins.com
Welding, Brazing and Cutting General Liability Supplemental Application
(Complete in addition to ACORD General Liability Application)
Name of Applicant:
Web site Address:
Location Address:
ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE”
1. Indicate percentage of total operations for each type of welding/brazing/soldering process performed?
Type of Process Percent Type of Process Percent
Arc Welding
% Laser Beam Welding
%
Brazing
% Resistance Welding
%
Electron Beam Welding
% Soldering
%
Electroslag Welding
% Solid State Welding
%
Gas Welding
% Thermite Welding
%
Induction Welding
% Other (Describe below)
%
Describe “Other” process:
2. Percentage of operations performed: In Shop % Off Site/Mobile %
3. Total number of employees performing welding/brazing duties: .....................................................
a. Number of employees certified only by American Welding Society:..................................................
b. Number of employees certified only by American Society of Mechanical Engineers: .......................
c. Number of employees certified by both AWS and ASME: .................................................................
d. Number of employees that are not certified by either of the above: ..................................................
4. If work is performed by non-certified person, is work inspected and approved by a certified
welder? .......................................................................................................................................................
Yes No
5. Total annual Payroll: .............................................................................................................................. $
Total annual Receipts: ........................................................................................................................... $
Total annual Subcontracted Costs: ...................................................................................................... $
6. Work performed is: % Residential % Commercial % Industrial
GLS-APP-64s (3-12) Page 1 of 5
Submit Application
7. Indicate percentage of annual receipts for each type of work performed:
Type of Work
Percent
Type of Work
Percent
Aircraft/Aerospace
%
Machinery/Equipment*
%
Aluminum Containers
%
Metal Erection:
Amusement Devices—mechanical
%
Balconies or Handrails
%
Automobile/Truck/Bus:
Catwalks or Staircases
%
Accessories, Bins, Racks
%
Decorative or Artistic
%
Bumpers, Trailer Hitches
%
Structural
%
Frame or Axle Work
%
Nonstructural
%
Roll Bars or Safety Cages
%
Outside Iron Work on Frame Structures
%
Other* (Describe below)
%
Standpipes, Watertowers, Silos
%
Bleachers
Off Shore Work*
%
Permanent
%
Oil Field Work*
%
Portable
%
Oil Field Work—Over the Hole
%
Boilers
%
Playground equipment
%
Bridges
%
Pipeline/Process Piping:
Building Construction (Structural):
Chemical (Non-Petrochem)
%
One or Two Story
%
Gas (LPG, Natural, etc.)
%
Three to Five Story
%
Food/Beverage Processing
%
Over Five Story
%
Gasoline/Oil
%
Caisson Work
%
Water
%
Contractors Equipment*
% Other* (Describe below)
%
Conveyor Systems
Pressure Vessels (Not Tanks)
%
Used in Mining
%
Railroad:
Other than Mining
%
Railroad Cars (other than tank cars)
%
Cutting of Scrap for Salvage or Recycling
%
Railroad Tank Cars
%
Demolition Operations
%
Railroad Tracks
%
Elevators or Feed Mills
%
Refinery, Chemical or Petrochemical Work
%
Fabrication
%
Security Doors
%
Farm Equipment*
%
Shipbuilding
%
Fence/Gate
%
Tanks:
Forklift/Lift Truck Repair
%
Pressurized
%
Furniture
%
Non-pressurized
%
Guardrail Erection/Repair
%
Tuna Towers
%
Ladders
%
Window Bars/Guards
%
“Live Line” Process Piping
%
Other* (Describe below)
%
Logging Equipment
%
Describe “other” work and explain in detail any operation indicated by * above:
GLS-APP-64s (3-12) Page 2 of 5
8. Does your company specialize in a certain industry or certain type of welding? .............................. Yes No
If yes, describe:
9. Off-Site/Mobile Operations:
a. Are fire extinguishers and first aid kit taken to each job site? ............................................................... Yes No
b. Describe site preparation procedures taken to prevent fire losses or injury to others:
10. Does the applicant subcontract work to others? ................................................................................... Yes No
If yes, describe type of work subcontracted:
11. 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
12. Does the applicant rent welding equipment or supplies to others? .................................................... Yes No
If yes, annual receipts: .............................................................................................................................. $
13. Does the applicant repair welding equipment for others? .................................................................... Yes No
If yes, are you factory authorized for such repairs? .................................................................................... Yes No
14. Does applicant operate a machine shop? .............................................................................................. Yes No
15. Does applicant sell welding rods (wholesale or retail)? ........................................................................ Yes No
16. Does the applicant offer rental, sales, service, filling or refilling of gas cylinders? .......................... Yes No
If yes, annual receipts: .............................................................................................................................. $
17. Does the applicant build or manufacture a finished product? ............................................................. Yes No
If yes, describe type of products manufactured:
18. Does applicant or subcontractor use explosives? ................................................................................ Yes No
If yes, describe:
19. Does applicant perform any welding operations over three stories? .................................................. Yes No
20. Hold-Harmless Agreements:
a. Does the applicant use a standard client contract, which outlines the specific responsibilities of the
applicant? ..............................................................................................................................................
Yes No
b. Do others hold applicant harmless? ...................................................................................................... Yes No
c. Does applicant agree to hold any third party harmless? ....................................................................... Yes No
d. Does applicant assume, by contract or verbally, responsibility for any injury or damage that may
occur? .................................................................................................................................................... Yes No
21. Does applicant have Workers’ Compensation coverage in force? ...................................................... Yes No
Does applicant lease employees? ............................................................................................................... Yes No
22. Does applicant have Professional Liability coverage in force? ........................................................... Yes No
GLS-APP-64s (3-12) Page 3 of 5
23. Attach (A) Any descriptive advertising literature; (B) Copy of applicants’ standard contract with clients’; (C)
Copies of all agreements in which the applicant has assumed liability; and (D) Separate detailed narrative de-
scriptions as required.
24 Does risk engage in the generation of power, other than emergency back-up power, for their
own use or sale to power companies?....................................................................................................
Yes No
If yes, describe:
This application does not bind the applicant nor the Company to complete the insurance, but it is agreed that the infor-
mation contained herein shall be the basis of the contract should a policy be issued.
FRAUD WARNING: 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 such person to criminal and civil penalties. Not applicable in Nebraska, Oregon and Vermont.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any in-
surer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a
felony in the third degree.
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 sub-
ject 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 a denial of
insurance benefits.
NOTICE TO MARYLAND APPLICANTS: Any person who knowingly and willfully presents a false or fraudulent claim for
payment of a loss or benefit or who knowingly and 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 MINNESOTA APPLICANTS: A person who files a claim with intent to defraud or helps commit a fraud
against an insurer is guilty of a crime.
NOTICE TO OHIO APPLICANTS: Any person who knowingly and with intent to defraud any insurance company 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 such person to criminal and civil penalties.
NOTICE TO OKLAHOMA APPLICANTS: 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 infor-
mation is guilty of a felony.
NOTICE TO RHODE ISLAND 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.
FRAUD WARNING (APPLICABLE IN TENNESSEE, VIRGINIA AND WASHINGTON): It is a crime to knowingly provide
false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penal-
ties include imprisonment, fines, and denial of insurance benefits.
GLS-APP-64s (3-12) Page 4 of 5
FRAUD WARNING APPLICABLE IN THE STATE OF NEW YORK: 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.
APPLICANT’S NAME AND TITLE:
APPLICANT’S SIGNATURE: DATE:
(Must be signed by an active owner, partner or executive officer)
PRODUCER’S SIGNATURE: DATE:
NAME AND PHONE NUMBER OF INDIVIDUAL TO CONTACT FOR INSPECTION/AUDIT:
GLS-APP-64s (3-12) Page 5 of 5
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Welding, Brazing and Cutting General Liability Supplemental Application (RT Specialty)

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Completed 13 December 2020

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