MACHINERY OR EQUIPMENT – INSTALLATION, SERVICING …



MACHINERY OR EQUIPMENT – INSTALLATION, SERVICING OR REPAIR APPLICATION SUPPLEMENT(To be used with Acord Application)Proposed First Named Insured & Other Named Insured(s): FORMTEXT ?????Mailing Address StreetCityCountyStateZIP Code FORMTEXT ?????Location Address StreetCityCountyStateZIP Code FORMTEXT ?????Website Address: FORMTEXT ?????Contact for Inspection/Audit:Name: FORMTEXT ?????Phone No.: FORMTEXT ?????PREVIOUS INSURER & LOSS HISTORY – Attach separate sheet if necessary FORMCHECKBOX See Loss Runs AttachedMissouri Applicants: DO NOT answer this question.Has insurance of this type been cancelled, refused, or nonrenewed by any company during the past 3 years? FORMCHECKBOX No FORMCHECKBOX Yes - If Yes, give name of company, date, and reason: FORMTEXT ?????Indicate all claims or losses (regardless of fault and whether or not insured) or occurrences that may give rise to claims for the past 3 years:YearCarrierPolicy NumberPremiumCoverageLosses/$ AmountDescription of Loss FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????If any losses in excess of $10,000, explain:BUSINESS INFORMATIONYears in Business: FORMTEXT ?????Years Experience: FORMTEXT ?????Are you licensed? FORMCHECKBOX Yes FORMCHECKBOX NoPercent of work for the following:Service: FORMTEXT ?????%Repair: FORMTEXT ?????%Describe operations: FORMTEXT ?????Commercial: FORMTEXT ?????%Residential: FORMTEXT ?????%Private Dwellings: FORMTEXT ?????%Any 24 Hour Emergency Service? FORMCHECKBOX Yes FORMCHECKBOX NoList all equipment installed, serviced, repaired or erected: FORMTEXT ?????Provide details of shop operations: FORMTEXT ?????Provide details of operations off premises: FORMTEXT ?????Do you install, service or repair work for the Petroleum or Chemical industry? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, describe: FORMTEXT ?????Annual Sales/Receipts: $ FORMTEXT ?????Do you perform any welding? FORMCHECKBOX Yes FORMCHECKBOX No If yes, FORMTEXT ?????%Do you distribute any foreign manufactured parts? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, provide a list of products: FORMTEXT ?????17.18.Do you repair or service invasive medical products, e.g. x-ray, MRI, CAT, Scan, Blood Analysis?Do you perform work on any of the following:Underground mining equipmentInstallation or work on playground equipment, waterslides, etc.Oil and gas equipment, well and drilling equipment, or over-the-hole workInstallation or service of logging equipmentTrash compactors and balersPetroleum refineriesChemical facilitiesGrain elevatorsRigging – not ship or boatHydraulic lifts used for auto repairAgriculture or farm equipment installation, service or repairGrinders, wood chippers, drilling equipment, sawsMedical-related equipment installation or repairYesNo FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 19.Provide payrolls for installation and repair work for the past 3 years:YearPayroll FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????20.Do you sell any used equipment? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, indicate percentage of your operation: FORMTEXT ?????%List used equipment sold: FORMTEXT ?????21.Provide 3 largest jobs performed in the past 12 months:DescriptionCost FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????22.Describe current work: FORMTEXT ?????23.Are subcontractors utilized? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, provide types of work subcontracted: FORMTEXT ?????24.Subcontracted costs: $ FORMTEXT ?????Verify all subcontractors carry equal limits and name applicant as Additional Insured.25.Do you utilize standard contracts when hiring subcontractors utilizing an Indemnity Clause? FORMCHECKBOX Yes FORMCHECKBOX NoFRAUD STATEMENTSFLORIDA: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.LOUISIANA and MAINE: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.Refer to the Core Application for all Fraud Statements.IMPORTANT NOTICEDECLARATIONI DECLARE THAT THE STATEMENTS MADE IN THIS APPLICATION ARE COMPLETE AND TRUE.As part of our underwriting procedures, a routine inquiry may be made to obtain applicable information concerning character, general reputation, and credit history. Upon your written request, additional information as to the nature and scope of the report, if one is made, will be provided.SIGNATURESApplicant SignatureTitleDateProducer SignatureDateProducer Name and Address ................
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