<p> GENERAL LIABILITY MACHINE SHOP SUPPLEMENTAL</p><p>GENERAL INFORMATION</p><p>Account Name: Effective Date: Description of Operation: Date:</p><p>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) %</p><p>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)</p><p>3. Provide examples of the types of products made.</p><p>4. What type of machines do you work on or construct parts for?</p><p>5. Percentage of Operations performed: In your shop Off Site/Mobile </p><p>6. Describe the site preparation procedures taken to prevent fire/heat losses or injury to others:</p><p>7. Do you build or manufacture a finished product? Yes Under your own label? Yes (If yes, please describe)</p><p>8. Do you design work or structural welding operations? Yes (If yes, please describe)</p><p>9. Do you design your own products or components? Yes (If yes, please describe)</p><p>10. Any work on conveyors, hoists, hydraulics? Yes (If yes, please describe)</p><p>11. Any manufacturing, refurbishing, or repair of valves of industrial pumps? Yes (If yes, please describe)</p><p>12. Any manufacturing of railings, window guards, balconies, staircases, fire escapes, or fire protective shelters? Yes (If yes, please describe)</p><p>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.)</p><p>14. Have you had any claims or reports of product performance? Yes (If yes, please describe)</p><p>15. List your five largest customers.</p><p>16. Please attach a copy of your standard client contract.</p><p>RISCOM P.O. Box 53017 Shreveport, Louisiana 71135 Phone: (866) 265-1557 Fax: (318) 698-6699 email: [email protected] www.riscomins.com</p>