Metalworkers/Plastics Supplemental Insurance Application

Transcription

1 Metalworkers/Plastics Supplemental Insurance Application Submission Requirements: Please check all that have been included: Completed & Signed ACORD applications REQUIRED; Five years currently valued loss runs REQUIRED; Business Income Worksheet REQUIRED FOR AGREED AMOUNT; Statement of Values REQUIRED FOR BLANKETED; MVRs REQUIRED FOR AUTO LIABILITY; Brochures; Web Site: Building Valuation Report Experience Mod. Worksheet REQUIRED FOR WORKERS COMPENSATION PART I GENERAL INFORMATION Named Insured: Phone: Company Contact: Phone: Street Address: P.O. Box County City, State, Zip Code: Location Name and Address: Coverage effective dates: From: To: Additional subsidiaries & descriptions: if any Number of years in business: Member of NTMA? No Yes: Chapter: 1. Annual Gross Sales: $ # Employees: # Shifts: 2. Is the general public allowed on the premises? Yes No 3. Work Product is sold to: commercial customers or general public 4. Work Product is sold: within US/Canada, outside US/Canada, or both 5. Final End Product is Sold to: commercial customers, general public, or Unknown 6. Does Insured design & market completed products? Yes No; Under private label Yes No List completed product(s) 7. Component Parts only? Yes No; a. Any assembly included? Yes No 8. Is Insured a Job Shop (products designed by others) Yes No; a. Design Assist Yes No; Does Customer Signoff on Adjustments Yes No b. What percentage of operations is to the specifications of the customer? % 9. Has the insured purchase any operations in the past ten years? Yes No 10. Does the insured have any discontinued products they sold? Yes No 11. Does the insured have any discontinued operations? Yes No Ed

2 12. Has the insured received any OSHA violations in the last 3 years? Yes No 13. Does the insured have any open citations? Yes No - If yes, how are they addressing the recommendation? 14. Has the Insured had any Property or Liability Claims in the past 5 years? Yes No 15. Any Work Subcontracted Out? Yes No; Are Certificates of Insurance Obtained? Yes No List Operation(s) PART II- EXPOSURES 16. Was this building originally designed and constructed for Current Operations? Yes No If no, what was the original building occupancy? If applicable, what year was the building retrofitted for use as a mfg. facility? 17. Building inspected or updated? Qualified Inspection Installed, Replaced or Updated Electric Heating Plumbing Roof 18. Is there an Automatic Fire Sprinkler System installed in all buildings? Yes No % of bldg How often is the sprinkler system tested? Date of last test? Sprinkler: Early Suppression (ESFR) Hydraulically Calculated Pipe Sched. Unknown Installed original with the building? Yes No; If no, when installed? Is there an auxiliary electrical supply system? Yes No 2. Is there an emergency lighting system? Yes No 3. Is there a Central Station Burglar Alarm System Yes No 4. Is there a Central Station Fire Alarm System Yes No 20. Cutting Oils: Petroleum Based Water Based Both Not Applicable 21. Use of Flammables/Chemicals/Solvents? Yes No; Separate UL approved Storage Yes No PART III- LOSS CONTROL 22. Does the insured maintain premises adequately? Inside Yes No; Outside Yes No 23. Are insured s premises fenced, or access to the location limited? Yes No 24. Where is scrap/stock stored? Inside Outside Both Is the property fenced? Yes No Is the property lighted? Yes No Security Guard? Yes No 25. Does insured back up all software, including computer operated machines, on a regular basis? Yes No, if so how often? 26. Does the insured have a vehicle maintenance program? Yes No

3 27. Check all that apply to the Insured s Employee Safety Program Back to Work Program Regular Safety Meetings Safety Committee/Officer Material Handling Procedures Lock Out/Tag Out Mandatory Personal Protective Equipment Accident Investigation Supervisor Training New Hire Training Proactive Management 28. Is All Work Inspected/Quality Controlled? Yes No; a. Is There a Formalized Rejection and Tracking Process? Yes No PART IV Industries Served INDUSTRIES SERVED: % OF TOTAL TOP THREE OR RECENT CUSTOMERS : Department of Defense % Industrial Machinery Computer or High Technology Tool Manufacturing Instrument Manufacturing Electronics Aerospace (Spacecraft/Satellite) Aviation (Airplane/Helicopter) Medical: Non Vital/Non Invasive Medical: Surgical/Invasive Motor Vehicle/Watercraft Petrochemical/Utility/Nuclear Consumer/Household Products Agricultural Machinery TOTAL % (must Equal 100%) 100% PART V Underwriting Information - METALS DESCRIPTION OF OPERATIONS: % OF TOTAL METALS USED IN OPERATIONS: % OF TOTAL Precision Parts Machining - CNC % Magnesium % Pattern/Mold Manufacturing Beryllium Sheet Metal (shearing, braking) Lithium Plastic Injection Manufacturing Aluminum Stamping Zirconium Turning Lathe Bismuth Grinding Cadmium Welding Tungsten Assembly Titanium Metal Heat Treating Other Ferrous (Mild, Carbon, Cast, etc.) Finishing(Plating/Anodizing/Oth) Other Non Ferrous Forging/Drawing Plastics Spraying/Coating/Painting Other (Describe Below) Foundry or Die Cast Mfg. TOTAL % (must Equal 100%) 100% TOTAL % (must Equal 100%) 100%

4 29. Is the Line Card/Equipment List available on the company s Website? Yes No a. Please provide a line card with the submission or complete below: Vert/Hor CNC Machine Centers, EDM Machines, FMS, Swiss PNC, Water Jet Cutting, Laser or Plasma Cutters, Grinders, Lathes, Presses; Forklifts PART VI Underwriting Information - PLASTICS PROCESSES USED: Blow Molding Compression Molding Injection Molding Rotational Molding Transfer Molding Extrusion: Sheet, plate, pipe Reaction Injection Molding Blown and Cast Film Extrusion Calendaring Co-extrusion Pressure Forming Vacuum Forming Foam Extrusion Pultrusion Fiberglass Lay-up or Spray-up Thermosetting Laminates Check that apply RESINS: ABS-Acrylonitrile-butadiene-styrene Acetal Acrylic Butyl Rubber EPDM-ethylene-polypropylene rubber FRP-Fiberglass-Reinforced polyester Nitrile Rubber PET-Polyethylene terephthalate Polybutadiene Polycarbonate Polyester Polyethylene Polypropyiene Polystyrene Polyurethane PVC-Polyvinyl chloride SAN-Styrene Acrylonitrile SBR-Styrene butadiene rubber Cellulosics(cellulose acetate/ethyl cellulose) Fluroplastics (ECTFE/ETFE/FEP) Nylon Fluroplastics (PCTFE/PTFE) Melamine Phenolic Urea Formaldehyde Check that apply 30. Ventilation/Duct System/Air Handling? a. Current System(s) (check all that apply): Dust Smoke Mist Fume Industrial Other b. How often inspected? Monthly Annually On Service Unknown Other c. How often cleaned? Monthly Annually On Service Unknown Other d. Are there scrubbing filters for discharge to outside air? Yes No Unknown 31. Is there a formal Fire Safety Training Program? Yes No Contact Person in charge of Fire Safety: 32. Outline Protective Safeguards for Employees from hot machinery and/or Materials:

5 PART VII- CURRENT COVERAGE A. Current insurance coverage: Carrier # Yrs Coverage Premium Effective Dates Property General Liability Auto Workers Comp Umbrella Aircraft Products Medical Benefits PART VI FINANCIAL INFORMATION A. Sales, Payroll & Vehicle history for the past five years: Year Sales Payroll # Vehicles Current Year First Prior Year Second Prior Year Third Prior Year Fourth Prior Year Fifth Prior Year COMMENTS/DESCRIPTION OF OPERATIONS: Attestation: The authorized signer of this application represents to the best of his/her knowledge and belief that the statements and information set forth herein are true and include all material information. The authorized signer also represents that any fact, circumstance or situation indicating the probability of a claim or legal action now known to any entity official or employee has been declared, and it is agreed by all concerned that the omission of such information shall exclude any such claim or action from coverage under the insurance being applied for. Signing of this application does not bine Nova Casualty or Aix Specialty Insurance Company to offer, nor the authorized signer to accept insurance, but it is agreed this application and any attachments hereto shall be the basis of the insurance and will be incorporated by reference and made part of the policy should a policy be issued. Insured s Signature: Name/Title: Date: Submitted by: Submission Date:

6 Rough Schematic of building(s) and surrounding exposures (Please indicate distance between buildings):