Allied General Agency Company

1100 Locust Street, Dept 2002, Des Moines, IA 50391-2002

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

Email:

WELDING ANDMACHINERY/EQUIPMENT REPAIR APPLICATION

Applicant’s Name: Agency Name:

Mailing Address: Address:

Contact Name:

Physical Location:______

PROPOSED EFFECTIVE DATE: ______

PLEASE ANSWER ALL QUESTIONS. IF THEY DO NOT APPLY, INDICATE ‘NOT APPLICABLE’.

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

2. Applicant Operations: Company website: ______Number of years in operation: ______

If new business, describe prior experience: ______

Number of owner/partners: ______Number of trade employees (not including owner/partners): ______

Gross annual payroll (excluding owners, partners & 100% clerical employees): ______

Gross annual subcontracted costs…………. $______Gross annual receipts ………… $______

Describe the type of work subcontracted:

Does the applicant require, and keep on file, proof of general liability insurance from all subcontractors, with limits equal to or greater than those on this application,that names the applicant as an additional insured? Yes No

A. WELDING – INDICATE TYPE OF WELDING BY PERCENTAGE:

Type of Process / % / Type of Process / %
Brazing / Laser Beam Welding
Arc Welding / Resistance Welding
Gas Welding / Solid State Welding
Electron Beam Welding / Thermite Welding
Electroslag Welding / Tungsten Inert Gas Welding (TIG)
Induction Welding / Other (Describe below)
Describe “other” process:

3.Percentage of operations performed:In Shop % Off Site/Mobile _____%

4.Premises and Off Site Safety Procedures:

Is premises equipped with fire extinguishers and/or alarm systems?...... Yes No

Are adequate number of fire extinguishers taken to mobile work sites?...... Yes No
Describe other safety precautions: ______

5. Are all welders certified by American Welding or American Society of Mechanical Engineers? Yes No

6.Does your company specialize in a certain industry or certain type of welding?...... Yes No

If Yes, describe:

7.Indicate by percentage if the applicant performs any of the following work:

Type of Work / % / Type of Work / %
Aircraft/Aerospace / Metal Erection:
Aluminum Containers / Decorative or Artistic
Automobile/Truck/Bus: / Nonstructural
Accessories, Bins, Racks / Standpipes, Watertowers, 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)
Conveyor Systems / Pressure Vessels (Not Tanks)
Cutting of Scrap for Salvage or Recycling / Railroad Tracks
Elevators or Feed Mills / Railroad Cars
Fence/Gate / Refinery, Chemical or Petrochemical Work
Forklift/Lift Truck Repair / Security Doors
Furniture / Shipbuilding
Guardrail Erection/Repair / Tanks:
Logging Equipment / Pressurized
Machinery/Equipment Service or Repair* (complete Section B) / Non-pressurized
Other* (Describe Below) / Window Bars/Guards
Describe “other” work and explain in detail any operation indicated by * above:

8.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

9.Does the applicant rent welding equipment or supplies to others?...... Yes No

If Yes, annual receipts:$......

Provide list of items rented: ______

10.Does the applicant repair welding equipment for others?...... Yes No

If Yes, are you factory authorized for such repairs?...... Yes No

11.Does the applicant offer rental, sales, service or filling or refilling of gas cylinders?...... Yes No

If Yes, annual receipts:$......

12.Does the applicant manufacture any parts and/or a finished product?...... Yes No

If yes, describe type of products or parts manufactured:
Product website: ______Gross annual receipts from product/parts: $______

B. MACHINERY/EQUIPMENT SERVICE OR REPAIR:

Type of Industry / % / Type of Work Performed (if any) / %
Construction / Hydraulics
Farm/Agriculture / Conveyors
Industrial / ATV’s, Snowmobiles, Jet Skis, etc.
Oil or Gas / Catwalks
Other* (describe below) / Medical Equipment
______
______/ Aerospace/Aircraft
Watercraft
Heavy Industrial Machinery
Logging Equipment
Grain Elevators/Bins/Silos

13.Does the applicant use a contract which outlines their specific responsibilities?...... Yes No

Do others hold applicant harmless?...... Yes No

Does applicant agree to hold any third party harmless?...... Yes No

Does applicant assume, by contract or verbally, responsibility for any injury or damage that
may occur?...... Yes No

14.Does applicant have Workers’ Compensation coverage in force?...... Yes No

Does applicant lease employees?...... Yes No

15.Does applicant have Professional Liability coverage in force?...... Yes No

16. Describe in detail, your 3 largest jobs:

1. ______

2. ______

3. ______

17.Provide the following if the applicant needs any additional insureds named on the policy:...... Yes No

Name: ______
Mailing Address: ______
Insurable Interest: ______

18. Loss Experience for General Liability and Property last 3 years (or # of yrs in business if < 3 yrs)

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

19.Has coverage ever been cancelled or non-renewed? Yes No

If yes, please explain:......

20.Inspection Contact: Inspection Contact Phone Number:

APPLICANT’S SIGNATURE: DATE:

(Must be signed by an active owner, partner or executive officer.)

PRODUCER’S SIGNATURE:DATE:

GLS-APP-64s (11-06)Page 1 of 4