11.) Do you work on any of the following?
12.) What type of welding/brazing/soldering process are performed?
Provide percentage of total operations for each type performed, equaling 100%.
13.) Percentage of operations performed:
Total of "In Shop" and Off site/Mobile" should equal 100%.
14.) Indicate percentage of welding work, if any, done on the following:
Provide percentage of annual receipts for each type of work. All percentages combined should equal 100%.
Prior Carrier Premium and Loss History:
Vehicle Mounted Equipment:
Your Unscheduled Tools and Equipment:
Blanket coverage on small tools and equipment.
Materials, Parts and Supplies:
Blanket coverage on expendable materials, parts, and supplies used in your business operations, but only while they are located in or on a described "Service Vehicle."
Bailee's Liability Extension:
Covers your legal liability for property of others in your care, custody, control while it is being worked on in the field, but it does not include coverage on such property at your own location(s).
NOTICE OF INSURANCE INFORMATION PRACTICES. In connection with this application for insurance ( and subsequent policy renewals), your personal information may be collected from persons other than you and without your authorization (e.g., credit reports). You have the right to preview your personal information in our files and may request correction of any inaccuracies contained therein. A more detailed description of your rights and our practices regarding such information will be available upon request and you may contact your agent or broker for instructions regarding how to submit this request to us.
Any person who knowingly files an application for insurance or a statement of claim with materially false information with the intent to defraud an insurance company or other person is committing a fraudulent insurance act. Moreover, any person who has concealed material facts for the purpose of providing misleading information is also committing a fraudulent insurance act. These acts are crimes and subjects the person to criminal and [NY:substantial] civil penalties. (Not applicable in CO, FL, HI, MA, NE, OH, OR, or VT; in DC, LA, ME, TN, VA and WA insurance benefits may also be denied). IN Florida, it is a third degree felony to knowingly file a statement of claim or any application containing false, incomplete, or misleading information with the intent to injure, defraud, and/or deceive any insurer.
The undersigned is an authorized representative of the applicant and acknowledges that reasonably inquiry has been made to obtain the information on this application. He/she acknowledges that the answers are true, correct and complete to the best of his/her knowledge.