SUPPLEMENTAL APPLICATION—Welding, Brazing and Cutting
(Complete in addition to ACORD Application)

1.	Name of Applicant: 	
2.	What type of welding / brazing / soldering processes are preformed? 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		
Electroslag Welding			Thermite Welding		
Induction Welding			Other (Describe below)		

Describe “Other” process: 	
	
3.	Percentage of operations performed: 	   In Shop __________%     Off Site/Mobile __________%
4.	Total number of employees performing welding / brazing duties.		
	No. of employees certified only by American Welding Society		
	No. of employees certified only by American Society of Mechanical Engineers		
	No. of employees certified by both AWS and ASME		
	No. of employees that are not certified by either of the above		
5.	If work is performed by non-certified person, is work inspected and approved by a certified welder?	 Yes   No
6.	Total annual Payroll	$	
	Total annual Receipts	$	
	Total annual Subcontracted Costs	$	
7.	Work performed is:	__________% Residential      __________% Commercial      __________% Industrial
8.	Does your company specialize in a certain industry or certain type of welding?	 Yes   No
	If Yes, describe:	
9.	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: 	

10.	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, 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)		
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.

	

11.	Does the applicant subcontract work to others?	 Yes   No
	If Yes, describe type of work subcontracted:	
12.	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
13.	Does the applicant rent welding equipment or supplies to others?	 Yes   No
If Yes, annual receipts:	$	
14.	Does the applicant repair welding equipment for others?	 Yes   No
If Yes, are you factory authorized for such repairs?	 Yes   No
15.	Does the applicant offer rental, sales, service or filling or refilling of gas cylinders?	 Yes   No
If Yes, annual receipts:	$	
16.	Does the applicant build or manufacture a finished product?	 Yes   No
If Yes, describe type of products manufactured.

	
17.	Hold-harmless Agreements:
Does the applicant use a standard client contract, which outlines the specific responsibilities
of the applicant?	 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
18.	Does applicant have Workers’ Compensation coverage in force?	 Yes   No
Does applicant lease employees?	 Yes   No
19.	Does applicant have Professional Liability coverage in force?	 Yes   No
20.	Does the applicant have a Web site?	 Yes   No
If Yes, provide Web site address:	
21.	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 descriptions as required.
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.
Contact Person:		Phone Number:		
			
	Applicant’s Signature	Date
Applicable in the State of Florida:
      Agent’s Name:   	
       Agent’s License No.