GENERAL LIABILITY
MACHINE SHOP SUPPLEMENTAL
GENERAL INFORMATION
Account Name:
Effective Date:
Description of
Operation:
Date:
1. What type(s) of activities does your company engage in? (Total should equal 100%)
Precision Machined Parts Manufacturing
%
Electroplating
%
Metal Goods Manufacturing - Stamping
%
Foundry
%
Die Cast Manufacturing
%
Metal Treating
%
Forging - Type
%
Welding (If over 20%, complete Suppl)
%
Instrument Manufacturing
%
Machine Shop Jobbing
%
Wholesale Distributor
%
Machine Shop – Custom
%
Industrial Manufacturing (please select one)
%
Metal Finishing
%
Assembly
%
Pattern Manufacturing
%
Electronic Manufacturing
%
Plastic Injection Molding
%
Fabrication
%
Sheet Metal Manufacturing
%
Tool Manufacturing
%
Other Services (please specify)
%
%
2.
Indicate percentage of products by industry group:
Aviation
%
Medical Equipment
Computer
%
Motor Vehicles
%
Defense
%
Nuclear
%
Electronic
%
Petrochemical
%
Household Appliance
%
Utilities
%
Industrial Machinery
%
Watercraft
%
Agricultural Machinery
%
Other Services (please specify)
%
3. Provide examples of the types of products made.
4. What type of machines do you work on or construct parts for?
5. Percentage of Operations performed:
In your shop
Off Site/Mobile
6. Describe the site preparation procedures taken to prevent fire/heat losses or injury to others:
7. Do you build or manufacture a finished product?
Yes Under your own label?
RISCOM
P.O. Box 53017
Shreveport, Louisiana 71135
Phone: (866) 265-1557
Fax: (318) 698-6699
email: instyquote@riscomins.com
Yes (If yes, please describe)
www.riscomins.com
8. Do you design work or structural welding operations?
9. Do you design your own products or components?
10. Any work on conveyors, hoists, hydraulics?
Yes (If yes, please describe)
Yes (If yes, please describe)
Yes (If yes, please describe)
11. Any manufacturing, refurbishing, or repair of valves of industrial pumps?
Yes (If yes, please describe)
12. Any manufacturing of railings, window guards, balconies, staircases, fire escapes, or fire protective shelters?
Yes (If yes, please describe)
13. Do you have a contract with a hazardous waste contractor to dispose of cutting oils, solvents, etc?
Yes (If yes, please attach a copy of the contract.)
14. Have you had any claims or reports of product performance?
Yes (If yes, please describe)
15. List your five largest customers.
16. Please attach a copy of your standard client contract.
RISCOM
P.O. Box 53017
Shreveport, Louisiana 71135
Phone: (866) 265-1557
Fax: (318) 698-6699
email: instyquote@riscomins.com
www.riscomins.com