(Fields marked * are required.)

Welding Contractors Application

Section 1: APPLICANT INFORMATION














Section 2: GENERAL LIABILITY UNDERWRITING INFORMATION


Do you work on the following risks:

Yes No
Yes No
Yes No
Yes No

Non-Upstream Oil & Gas:
Yes No
Yes No
Yes No
Yes No
** Refinery, Petrochemical Plants & Petrochemical Distributer Work Permissible Subject to:
  • During turnaround only at facility, which is defined as a non-operational facility undergoing maintenance, that is not in process of either shut-down or start up, & whereby the process equipment & piping had been purged of air by an inert gas.
  • No work at operational facilities

Breakdown of Receipts ($)


Operations Background




(Select at least one area of operations. You may select more than one area.)


Yes No

Please note that we do not offer coverage in the United States.

Total Number of Employees: /


Insured's Qualifications





Yes No


New Projects Repair Work Both
Mounted Portable
Yes No

Section 3: Loss Control Procedures

  1. Yes No
  2. Yes No
  3. Yes No
  4. Yes No
  5. Yes No

Section 4: Subcontracting Information

  1. Yes No
  2. Yes No
  3. Yes No

Section 5: Miscellaneous


Section 6: Insurance & Loss History Information



Yes No

Section 7: Claims

Claims Experience: Describe all claims in the last five years (include all relevant details, such as dates)

Truck / Auto
Yes No



Property (i.e. Deck, Welder, Tools)
Yes No



Liability
Yes No


Section 8: Insurance Requirements

Commercial General Liability
$2,000,000 $3,000,000 $5,000,000 $10,000,000 Other

SCHEDULE OF PROPERTY TO BE INSURED

The following form allows you to enter in all relevant truck, equipment, and tools that are to be included as part of your insurance coverage. For each additional item to be added, click the "Add another row" button at the end of the form to add more space.

Truck, Equipment & Large Tools:


$1000 $5000 $10000 Other
Yes No

Referral

NOTICE TO APPLICANT

Consumer and previous insurer reports containing personal, credit, factual or investigative information about the applicant may be sought in connection with this Applicant for Insurance or any renewal, extension or variation thereof. All provisions contained in the various forms issued under this contract shall be deemed to be contained in the present Application of Insurance. The policy may be deemed to be void and claims may be denied where:
  1. An Applicant for a contract:
    1. Gives false or erroneous information to the prejudice of the insurer, or
    2. Knowingly misrepresents or fails to disclose in the Application any fact required to be stated therein; or
  2. The Insured contravenes a term of the Contract or commits a fraud; or
  3. The Insured willfully makes a false statement in respect of a claim under the contract

YOU CERTIFY THAT ALL STATEMENTS MADE IN THIS APPLICATION ARE COMPLETE AND ACCURATE AND APPLY FOR A CONTRACT OF INSURANCE BASED UPON THE TRUTH OF THE STATEMENTS.

YOU ARE IN AGREEMENT THAT THIS DECLARATION SHALL HEREBY FORM PART OF THE INSURANCE AGREEMENT.

I accept the terms *: