General Liabilitymachine Shop Supplemental

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 % Electropla % ting 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 %0% Assembly Pattern Manufacturing % Electronic % Manufact uring Plastic Injection Molding % Fabricatio % n Sheet Metal Manufacturing % Tool % Manufact uring Other Services (please specify) %

2. Indicate percentage of products by industry group: Aviation % Medical % Equipmen t Computer % Motor % Vehicles Defense % Nuclear % Electronic % Petroche % mical Household Appliance % Utilities % Industrial Machinery % Watercraf % RISCOM P.O. Box 53017 Shreveport, Louisiana 71135 Phone: (866) 265-1557 Fax: (318) 698-6699 email: [email protected] www.riscomins.com t 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? Yes (If yes, please describe)

8. Do you design work or structural welding operations? Yes (If yes, please describe)

9. Do you design your own products or components? Yes (If yes, please describe)

10. Any work on conveyors, hoists, hydraulics? 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: [email protected] www.riscomins.com