Allied General Agency Company

1100 Locust Street, Dept 2002

Des Moines, IA50391-2002

Ph: 888-364-3434 Fax: 866-433-4331

Email:

Manufacturing Questionnaire

ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE NOT APPLICABLE

Applicant’s NameAgency Name

Mailing AddressAgent

Address

Location

E-mail

Web site AddressPhone

PROPOSED EFFECTIVE DATE: FromTo12:01 A.M., Standard Time at the address of the Applicant

1. Applicant is: Individual Corporation Partnership Joint Venture Other (Specify):

2. Limits of liability: $100,000/$200,000 $300,000/$600,000 $500,000/$1,000,000 $1,000,000/$2,000,000

Operation:
Form of raw material:
Finished product(s):
Detailed description of manufacturing process:
To be completed for each location.
Is process automated, computer operated or manual?
Sprinklered?...... YesNo
Type:
Dust Collection system?...... YesNo
Type:
Storage of dust at least 50 feet away from buildings?...... YesNo
Is dust used for fuel?...... YesNo
Any dry kilns on premises?...... YesNo
If yes, how many?
Ventilation system?...... YesNo
Type:
Condition of overall housekeeping:
Night clean up crew?...... YesNo
Is there 24-hour security?...... YesNo
Premises fenced?...... YesNo
How is raw material moved to production area?ConveyorsAugerOverhead Cranes Forklifts
Other:
Is electrical equipment and wiring explosion proof?...... YesNo
All process equipment grounded and bonded?...... YesNo
Does equipment have automatic shut-off?...... YesNo
What is the age of the processing equipment?
What is the inspection and servicing schedule for all equipment (including converyors, hydraulic lines, etc.)?
How often is the electrical equipment and wiring inspected and serviced by a licensed professional?
Are you in compliance with NFPA 70 on eletrical codes?...... YesNo
Are you in compliance with NFPA 77 on static electricity?...... YesNo
Does production machinery have dust tight seals and explosion venting?...... YesNo
Is smoking allowed on premises?...... YesNo
If yes, describe designated premises:
Storage of Raw Material:
What form is raw material stored in?
Is storage of raw material separated from production and finished product?...... YesNo
If yes, by:FirewallsSeparate BuildingOther:
What is the average size of stockpiles?
Storage of Chemicals, Flammables or Solvents, etc.:
Is storage separated from all other operations?...... YesNo
If yes, by:FirewallsSeparate BuildingOther:
What other chemicals, flammables or solvents are used (include trade names.)?
Quanity of each?
Container type, size and number of gallons?
Are Material Data Safety Sheets on file and availalbe?...... YesNo
Describe any cadmium, magnesium, zirconium or titanium:
Are all 55 gallon drums storing chemicals properly grounded?...... YesNo
Is only a single day’s supply stored on the premises?...... YesNo
If no, how much?
Is storage area properly ventilated?...... YesNo
If no, what kind of ventilating is used?
Are you in compliance with NFPA 30 standards?...... YesNo
Storage of Finished Product:
Is storage of finished products separated from the production area?...... YesNo
If yes, by:FirewallsSeparate BuildingOther:
What is the average size of the stockpiles?
Do you have trained in house fire brigade?...... YesNo
What is the response time from the Fire Department?
Do you have your own water source on site?...... YesNo
If yes, describe:
Do you have your own firefighting equipment on site?...... YesNo
If yes, describe:
Are there grinding or finishing operations?...... YesNo
If yes, is there a shield guard?...... YesNo
Please provide details on these operations:
Are there painting or laminating operations?...... YesNo
U/L approved paint booth?...... YesNo
If no paint booth, describe how it is controlled:
Are there welding operations?...... YesNo
If yes, are hot work permits obtained?...... YesNo
Fire watch?...... YesNo
If yes, separate cut off area from other operations?...... YesNo
Are there woodworking operations?...... YesNo
If yes, are all operations or equipment covered by dust collection system?...... YesNo
Where is collectable sawdust stored?

Loss Experience for General Liability and Property last 3 years (or # of yrs in business if < 3 yrs) No Losses

YEAR / COMPANY / POLICY
NUMBER / PREMIUM / LOSSES
PAID / LOSSES
RESERVED / DESCRIPTION

Prior Carrier: Was prior coverage ever cancelled or non-renewed? Yes No

If yes, please explain:______

APPLICANT’S SIGNATURE: DATE:

AGENT NAME: AGENT LICENSE NUMBER:

INSPECTION/AUDIT CONTACT NAME & NUMBER:

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.

ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE”

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CFS-QUES-2 (3-02)