Fillable Welding Supplemental Application (Special Risks)

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Welding Supplemental Application (Special Risks)

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S381s (11/15) Contains copyrighted material of Insurance Services Office, Inc., with its permission. Page 1 of 6
Welding Supplemental Application
TO BE USED WITH COMMERCIAL GENERAL LIABILITY APPLICATION (S308 or Equivalent)
All questions must be answered in full. Application must be signed and dated by the applicant.
If additional space is needed to answer any question, attach a separate detailed narrative description.
Applicant’s Name
Agent
Applicant Mailing Address
Applicant’s Phone Number
Web Address
Inspection Contact
Proposed Policy Period to
Phone Number for Inspection Contact
Applicant is Individual Partnership Corporation Joint Venture LLC Other
Location #1
Location #2
Location #3
UNDERWRITING INFORMATION
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
%
Thermal Welding
%
Induction Welding
%
Other (Describe below)
%
Describe “Other” processes:
State(s):
3. Is applicant bonded? ........................................................................................................................................ Yes No
4. Indicate what percentage of work is on or off premises.
On premises %
Off premises %
5. Number of employees performing welding/brazing duties:
a. Certified only by American Welding Society (AWS): ..............................................................................................
b. Certified only by American Society of Mechanical Engineers (ASME): ..................................................................
c. Certified by both AWS and ASME: .........................................................................................................................
d. Not certified by either AWS or ASME: ....................................................................................................................
6. If work is performed by non-certified persons, is work inspected and approved by a certified welder? ........... Yes No
If not, explain:
Agency Name:
Address:
Contact Name:
Phone:
Fax:
Email:
S381s (11/15) Contains copyrighted material of Insurance Services Office, Inc., with its permission. Page 2 of 6
7. Indicate percentage of annual receipts for each type of work performed:
Type of Work
Percentage
Type of Work
Percentage
Aircraft/Aviation/Aeronautics/Aerospace
%
Machinery or Equipment*
%
Aluminum Containers
%
Manufacturing*
%
Amusement Devices* – mechanical
%
Metal Erection:
Amusement Rides
%
Balconies or Handrails
%
Any Operations In, On, Over or Under
Water
%
Catwalks
%
Decorative or Artistic
%
Automobile/Truck/Bus:
Staircases
%
Accessories, Bins, Racks
%
Structural
%
Bumpers, Trailer Hitches
%
Nonstructural
%
Frame, Chassis or Axel Work
%
Outside Iron Work - Frame Structures
%
Roll Bars or Safety Cages
%
Standpipes, Water Towers or Silos
%
Other* (Describe below)
%
Nuclear Power Generation Plants
%
Bleachers:
Off Shore Work*
%
Permanent
%
Oil or Gas Work:
Portable
%
Over-The-Hole
%
Bridges
%
Drilling Derricks or Rigs
%
Building Construction (Structural)
Gas Tanks, Lines or Pipes
%
One to Three Stories
%
Refineries
%
Over Three Stories
%
Petrochemical Plants
%
Caisson or Cofferdam Work
%
Playground Equipment
%
Chemical or Petrochemical Plants
%
Pipeline or Process Piping:
Contractors Equipment*
%
Chemical (Non-Petrochemical)
%
Conveyor Systems:
Gas (LPG, Natural, etc.)
%
Used in Mining
%
Food or Beverage Processing
%
Other than Mining
%
Gasoline or Oil
%
Cranes
%
Water
%
Custom-built Trailers
%
Other* (Describe below)
%
Cutting of Scrap for Salvage or Recycling
%
Pressure Vessels
Demolition Operations
%
Boilers
%
Fabrication
%
Oxygen Cylinders
%
Farm Equipment*
%
Steam Pipes
%
Fences or Gates
%
Welding Gas Cylinders
%
Forklift or Lift Truck Repair
%
Other* (Describe below)
%
Furniture
%
Railroad Work
%
Grain Bins, Silos, Elevators or Feed Mills
%
Recreational Vehicles
Guardrail Erection or Repair
%
ATVs
%
Hoists
%
Go-Karts
%
Ladders
%
Snowmobiles
%
Large Equipment*
%
Motorized Trailers
%
“Live Line” Process Piping
%
Travel Trailers
%
Logging Equipment
%
Other* (Describe below)
%
S381s (11/15) Contains copyrighted material of Insurance Services Office, Inc., with its permission. Page 3 of 6
7. Indicate percentage of annual receipts for each type of work performed (continued):
Type of Work
Percentage
Type of Work
Percentage
Refineries
%
Towers
Scaffolding/ Catwalks
%
100 ft. in height and under
%
Security Doors
%
Greater than 100 ft. in height
%
Ship, Boat or Yacht Building
%
Trailer Hitch Manufacturing. or Fabricating
%
Tanks:
Window Bars or Guards
%
Pressurized
%
Other* (Describe below)
%
Non-Pressurized
%
Describe “Other” work and explain in detail any operation indicated by an asterisk (*) above:
8. Total annual:
a. Payroll .................................................................................................................................................................... $
b. Receipts: ................................................................................................................................................................ $
c. Subcontracted Costs: ............................................................................................................................................. $
9. What is the end-use of items being welded (industries used in, specific customers, end result, exposure)?
10. Does the applicant fabricate or manufacture any products? ............................................................................... Yes No
If yes:
a. Is it being done per customer’s specifications? ............................................................................................ Yes No
b. Does applicant do the design work? ............................................................................................................ Yes No
c. Does applicant receive sign-off on drawings and specifications? ................................................................ Yes No
d. Describe the types of products fabricated or manufactured:
11. Are fire extinguishers and first aid kits provided at all job sites? .......................................................................... Yes No
12. Describe site preparation procedures taken to prevent fire losses and injuries to others:
13. Is any work done on existing oil or gas lines? ..................................................................................................... Yes No
If yes:
a. Are all lines purged and flushed prior to welding? ......................................................................................... Yes No
b. Are the lines ever pressurized during the work process? .............................................................................. Yes No
S381s (11/15) Contains copyrighted material of Insurance Services Office, Inc., with its permission. Page 4 of 6
UNDERWRITING INFORMATION (Continued)
14. Does applicant rent welding equipment or supplies to others? ........................................................................... Yes No
If yes, what are the annual gross receipts? .................................................................................................................... $
15. Does the applicant repair welding equipment for others? ................................................................................... Yes No
If yes, are you factory authorized for such repairs?............................................................................................. Yes No
16. Does applicant:
a. Operate a machine shop? ............................................................................................................................ Yes No
b. Perform any demolition work? ...................................................................................................................... Yes No
c. Do any metal heat processing? .................................................................................................................... Yes No
d. Operate a welding supply store? .................................................................................................................. Yes No
17. Is applicant a distributor or manufacturer of welding supplies or equipment? ..................................................... Yes No
18. How are welding tanks secured?
19. Does applicant have any bulk storage tanks or perform their own mixing operations? ....................................... Yes No
20. Does applicant sell welding rods (wholesale or retail)? ....................................................................................... Yes No
21. Does applicant offer rental, sales, service, filling or refilling of gas cylinders? .................................................... Yes No
If yes, what are the annual gross receipts? .................................................................................................................... $
22. Does the applicant subcontract work to others?.................................................................................................. Yes No
If yes:
a. Does applicant obtain proof of insurance from subcontractors? .................................................................. Yes No
b. Is the applicant named as additional insured on the subcontractors policy? ................................................ Yes No
c. Describe types of work subcontracted:
23. Does applicant have any of the following types of machinery?
a. Conveyors? .................................................................................................................................................. Yes No
b. Cranes? ....................................................................................................................................................... Yes No
c. Forklifts? ...................................................................................................................................................... Yes No
d. Farm Equipment? ........................................................................................................................................ Yes No
If yes, described how they are used:
24. Does applicant or subcontractor use explosives? ............................................................................................... Yes No
25. Contractual Agreements:
a. Does the applicant use a standard client contract, which outlines applicant’s specific responsibilities? ...... Yes No
b. Do others hold applicant harmless? ............................................................................................................. Yes No
If yes, explain:
c. Does applicant agree to hold any third party harmless? .............................................................................. Yes No
If yes, explain:
d. Does applicant assume, by contractor or verbally, responsibility for any injury
or damage that may occur? ......................................................................................................................... Yes No
If yes, explain:
26. Attach:
a. Any descriptive advertising literature.
b. Copy of applicants’ standard contract with customers and subcontractors.
c. Copies of all agreements in which the applicant has assumed liability.
S381s (11/15) Contains copyrighted material of Insurance Services Office, Inc., with its permission. Page 5 of 6
PLEASE READ BELOW AND COMPLETE SIGNATURE BLOCK ON LAST PAGE
I have reviewed this application for accuracy before signing it. As a condition precedent to coverage, I hereby
state that the information contained herein is true, accurate and complete and that no material facts have been
omitted, misrepresented or misstated. I know of no other claims or lawsuits against the applicant and I know of
no other events, incidents or occurrences which might reasonably lead to a claim or lawsuit against the applicant.
I understand that this is an application for insurance only and that completion and submission of this application
does not bind coverage with any insurer.
IMPORTANT NOTICE: As part of our underwriting procedure, a routine inquiry may be made to obtain applicable
information concerning character, general reputation, personal characteristics, and mode of living. Upon written
request, additional information as to the nature and scope of the report, if one is made, will be provided.
FRAUD STATEMENT FOR THE STATE(S) OF:
Alabama, Alaska, Arizona, Arkansas, California, Connecticut, Delaware, District of Columbia, Georgia,
Idaho, Illinois, Indiana, Iowa, Louisiana, Massachusetts, Michigan, Minnesota, Mississippi, Missouri,
Montana, Nebraska, Nevada, New Hampshire, North Carolina, North Dakota, Rhode Island, South
Carolina, South Dakota, Texas, Utah, Vermont, West Virginia, Wisconsin, Wyoming: 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.
Colorado: 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.
Florida: 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.
Hawaii: Intentionally or knowingly misrepresenting or concealing a material fact, opinion or intention to obtain
coverage, benefits, recovery or compensation when presenting an application for the issuance or renewal of an
insurance policy or when presenting a claim for the payment of a loss is a criminal offense punishable by fines or
imprisonment, or both.
Kansas: Any person who commits a fraudulent insurance act is guilty of a crime and may be subject to restitution,
fines and confinement in prison. A fraudulent insurance act means an act committed by 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 or insurance agent or broker, any written, electronic,
electronic impulse, facsimile, magnetic, oral or telephonic communication or statement as part of, or in support of,
an application for insurance, or the rating of an insurance policy, or a claim for payment or other benefit under an
insurance policy, which such person knows to contain materially false information concerning any material fact
thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto.
Kentucky, Ohio, Pennsylvania: 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.
Maine, Tennessee, Virginia, Washington: 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.
Maryland: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or
benefit or 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.
New Jersey: Any person who includes any false or misleading information on an application for an insurance
policy is subject to criminal and civil penalties.
New Mexico: 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.
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.
S381s (11/15) Contains copyrighted material of Insurance Services Office, Inc., with its permission. Page 6 of 6
Oklahoma 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.
Oregon: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or
knowingly presents materially false information in an application for insurance may be guilty of a crime and may
be subject to fines and confinement in prison.
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Welding Supplemental Application (Special Risks)

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Completed 9 July 2021

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