CR BUREAU ID NUMBER LOC # BLD # STREET, CITY, COUNTY, STATE, ZIP+4 CITY LIMITS INTEREST YR BUILT # EMPLOYEES PART OCCUPIED OUTSIDE TENANT

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1 COD COC NSUNC PPCON PPCN NFOON SCON GNCY PHON NC COD: UNDW FX (/C, No.): POCS O POG QUSD POCY NUB D (/DD/YYYY) UNDW OFF. COD: GNCY CUSO D: SUS OF NSCON SUB COD: NDC SCONS CHD QUPN FO GG ND DS POPY NSON/BUDS SK VHC SCHDU GSS ND SGN CONC D POC BO & CHNY CCOUNS CVB/ VUB PPS COC GN BY WOKS COPNSON C/SCNOUS C BUSNSS UO UB NSPOON/ OO UCK CGO UCKS/OO QUO SSU POCY NW N HS NFOON WHN COON DS ND S PPY O SV NS, O FO ONON POCS. BOUND (Give Date and/or ttach Copy): POPOSD FF D POPOSD XP D BNG PN PYN PN UD CHNG D DC B CNC P GNCY B PPCN NFOON N (First Named nsured & Other Named nsureds) PCKG POCY NFOON FN O SOC SC # (of First Named nsured): PHON NG DDSS NC ZP+4 (of First Named nsured) - DDSS(S): NDVDU COPOON SUBCHP "S" COPOON C PNSHP JON VNU NO FO POF OG NO. OF BS ND NGS NSPCON CONC PHON WBS DDSS(S): C BUU D NUB N CCOUNNG CODS CONC PHON D BUS SD PSS NFOON OC # BD # S, CY, COUNY, S, ZP+4 CY S NS Y BU # POYS P OCCUPD NSD OWN OUSD NN NSD OUSD OWN NN NU OF BUSNSS/DSCPON OF OPONS BY PS(S) GN NFOON XPN "YS" SPONSS YS NO XPN "YS" SPONSS 1a. S H PPCN SUBSDY OF NOH NY? 7. NY PS OSSS O CS NG O SXU BUS O OSON GONS, DSCNON O NGGN HNG? 1b. DOS H PPCN HV NY SUBSDS? 8. DUNG H S FV YS (N N ), HS NY PPCN BN CONVCD OF NY DG OF H C OF SON? 2. S FO SFY POG N OPON? (n, this question must be answered by any applicant for property insurance. 3. NY XPOSU O FBS, XPOSVS, CHCS? Failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one year of imprisonment). 4. NY CSOPH XPOSU? 9. NY UNCOCD F COD VOONS? 5. NY OH NSUNC WH HS COPNY O BNG SUBD? 10. NY BNKUPCS, X O CD NS GNS H PPCN N H PS 5 YS? 6. NY POCY O COVG DCND, CNCD O NON-NWD 11. HS BUSNSS BN PCD N US? DUNG H PO 3 YS? (Not applicable in O) F YS, N OF US: KS/POCSSNG NSUCONS YS NO NY PSON WHO KNOWNGY ND WH NN O DFUD NY NSUNC COPNY O NOH PSON FS N PPCON FO NSUNC O SN OF C CONNNG NY Y FS NFOON, O CONCS FO H PUPOS OF SDNG, NFOON CONCNNG NY FC HO, COS FUDUN NSUNC C, WHCH S C ND SUBJCS H PSON O CN ND [NY: SUBSN] CV PNS. (Not applicable in CO, H, N, OH, OK, O, or V; in DC,,, N and V, insurance benefits may also be denied) H UNDSGND S N UHOZD PSNV OF H PPCN ND CFS H SONB NQUY HS BN D O OBN H NSWS O QUSONS ON HS PPCON. H/SH CFS H H NSWS U, COC ND COP O H BS OF HS/H KNOWDG. PPCN S SGNU D PODUC S SGNU NON PODUC NUB COD 125 (2003/01) PS COP VS SD COD COPOON 1993

2 PO NFOON N C O C G N B Y U O B O B Y P O P Y CGOY POCY NUB POCY YP O D GN GGG PODUCS COP OP GGG PSON & DV NJ CH OCCUNC F DG DC XPNS S BODY OCCUNC NJUY GGG POPY OCCUNC DG GGG COBND SNG ODFCON FCO O PU POCY NUB POCY YP COBND SNG BODY PSON NJUY CCDN POPY DG ODFCON FCO O PU POCY NUB POCY YP BUDNG PS POP ODFCON FCO O PU POCY NUB POCY YP ODFCON FCO O PU OSS HSOY CS CS CS CS CS OCCUNC OCCUNC OCCUNC OCCUNC OCCUNC D D D D D N CS O OSSS (GDSS OF FU ND WHH O NO NSUD) O OCCUNCS H Y GV S O CS FO H PO 5 YS (3 YS N KS & NY) CHK H F NON S CHD OSS SUY D OF D OUN OUN C N YP/DSCPON OF OCCUNC O C OCCUNC OF C PD SVD SUS OPN COSD OPN KS NO: FDY QUS FV Y OSS HSOY CHNS COSD S SUPPN(S) (f applicable) COPY OF H NOC OF NFOON PCCS (PVCY) HS BN GVN O H PPCN. (Not applicable in all states, consult your agent or broker for your state s requirements.) NOC OF NSUNC NFOON PCCS PSON NFOON BOU YOU, NCUDNG NFOON FO CD PO, Y B COCD FO PSONS OH HN YOU N CONNCON WH HS PPCON FO NSUNC ND SUBSQUN POCY NWS. SUCH NFOON S W S OH PSON ND PVGD NFOON COCD BY US O OU GNS Y N CN CCUSNCS B DSCOSD O HD PS WHOU YOU UHOZON. YOU HV H GH O VW YOU PSON NFOON N OU FS ND CN QUS COCON OF NY NCCUCS. O DD DSCPON OF YOU GHS ND OU PCCS GDNG SUCH NFOON S VB UPON QUS. CONC YOU GN O BOK FO NSUCONS ON HOW O SUB QUS O US. COD 125 (2003/01)

3 COD PODUC PHON COC GN BY SCON PPCN (First Named nsured) D COD: GNCY CUSO D: COVGS SUB COD: P C P OCCUNC FFCV D XPON D DC B PYN PN UD FO COPNY US ONY COC GN BY GN GGG $ PUS CS D PODUCS & COPD OPONS GGG $ OWN'S & CONCO'S POCV PSON & DVSNG NJUY $ CH OCCUNC $ DDUCBS DG O ND PSS (each occurrence) $ POPY DG BODY NJUY $ $ $ OCCUNC S DC XPNS (ny one person) $ POY BNFS $ GNCY B OH COVGS, SCONS ND/O NDOSNS (For hired/non-owned auto coverages attach the Business uto Section, COD 127) PSS/OPONS PODUCS OH O SCHDU OF HZDS OCON CSSFCON CSS PU # COD BSS XPOSU PU P/OPS PODUCS P/OPS PODUCS NG ND PU BSS (P) PYO - P $1,000/PY (C) O COS - P $1,000/COS (U) UN - P UN (S) GOSS SS - P $1,000/SS () - P 1,000/SQ F () DSSONS - P 1,000/D () OH CS D (xplain all "Yes" responses) 1. POPOSD OCV D: 1. DDUCB P C: $ 2. NY D NO UNNUPD CS D COV: 2. NUB OF POYS: 3. HS NY PODUC, WOK, CCDN, O OCON YS NO BN XCUDD, UNNSUD O SF-NSUD 3. NUB OF POYS COVD BY POY BNFS PNS: FO NY PVOUS COVG? 4. OCV D: 4. WS COVG PUCHSD UND NY PVOUS POCY? KS POY BNFS BY KS COD 126 (2000/04) PS COP VS SD COD COPOON 1993

4 CONCOS XPN "YS" SPONSS (For past or present operations) YS NO XPN "YS" SPONSS (For past or present operations) YS NO 1. DOS PPCN DW PNS, DSGNS, O SPCFCONS 4. DO YOU SUBCONCOS CY COVGS O S FO OHS? SS HN YOUS? 2. DO NY OPONS NCUD BSNG O UZ O SO 5. SUBCONCOS OWD O WOK WHOU XPOSV? POVDNG YOU WH CFC OF NSUNC? 3. DO NY OPONS NCUD XCVON, UNNNG, 6. DOS PPCN S QUPN O OHS WH O UNDGOUND WOK O H OVNG? WHOU OPOS? KS/DSCB H YP OF WOK SUBCONCD $ PD O SUB- % OF WOK # FU- # P- CONCOS: SUBCONCD: SFF: SFF: PODUCS/COPD OPONS N XPCD PODUCS NNU GOSS SS # OF UNS K F NNDD US PNCP COPONNS XPN "YS" SPONSS (For any past or present product or operation) YS NO XPN "YS" SPONSS (For any past or present product or operation) YS NO 1. DOS PPCN NS, SVC O DONS PODUCS? 6. PODUCS CD, DSCONNUD, CHNGD? 2. FOGN PODUCS SOD, DSBUD, USD S COPONNS? 7. PODUCS OF OHS SOD O -PCKGD UND 3. SCH ND DVOPN CONDUCD O NW PPCN B? PODUCS PNND? 8. PODUCS UND B OF OHS? 4. GUNS, WNS, HOD HSS GNS? 9. VNDOS COVG QUD? 5. PODUCS D O CF/SPC NDUSY? 10. DOS NY ND NSUD S O OH ND NSUDS? PS CH U, BOCHUS, BS, WNNGS, C DDON NS/CFC CPN NS NK: N ND DDSS FNC #: CFC QUD NS N NUB DDON NSUD OCON: BUDNG: OSS PY VHC: BO: OGG NHOD POY S SSO GN NFOON DSCPON: SCHDUD NUB: XPN "YS" SPONSS (For all past or present operations) YS NO XPN "YS" SPONSS (For all past or present operations) YS NO 1. NY DC FCS POVDD O DC POFSSONS POYD O CONCD? KS OH 12. NY SUCU ONS CONPD? 13. NY DOON XPOSU CONPD? 2. NY XPOSU O DOCV/NUC S? 14. HS PPCN BN CV N O S CUNY CV N 3. DO/HV PS, PSN O DSCONNUD OPONS JON VNUS? NVOV(D) SONG, NG, DSCHGNG, PPYNG, DSPOSNG, O NSPONG OF HZDOUS? 15. DO YOU S POYS O O FO OH POYS? (e.g. landfills, wastes, fuel tanks, etc) 4. NY OPONS SOD, CQUD, O DSCONNUD N S 5 YS? COD 45 attached for additional names 16. S H BO NCHNG WH NY OH BUSNSS O SUBSDS? 17. DY C FCS OPD O CONOD? 5. CHNY O QUPN OND O ND O OHS? 18. HV NY CS OCCUD O BN PD ON 6. NY WCF, DOCKS, FOS OWND, HD O SD? YOU PSS WHN H S H YS? 7. NY PKNG FCS OWND/ND? 19. S H FO, WN SFY ND SCUY 8. S F CHGD FO PKNG? POCY N FFC? 9. CON FCS POVDD? 20. DOS H BUSNSSS' POOON U K 10. S H SWNG POO ON H PSS? NY PSNONS BOU H SFY O SCUY 11. SPONG O SOC VNS SPONSOD? OF H PSS? NY PSON WHO KNOWNGY ND WH NN O DFUD NY NSUNC COPNY O NOH PSON FS N PPCON FO NSUNC O SN OF C CONNNG NY Y FS NFOON, O CONCS FO H PUPOS OF SDNG NFOON CONCNNG NY FC HO, COS FUDUN NSUNC C, WHCH S C ND SUBJCS H PSON O CN ND (NY: SUBSN) CV PNS. (NO PPCB N CO, H, N, OH, OK, O; N DC,, ND V, NSUNC BNFS Y SO B DND) COD 126 (2000/04) CH O PPCN NFOON SCON

5 WD S SUPPN QUSONN (Complete in ddition to ccord pplication) Name of pplicant: Base of Operations: 1. Does the applicant maintain a permanent shop? Yes No 2. What percentage of work is done in the shop? % 3. What percentage of work is done at job sites or customer locations? % ype of Operations 1. What type of welding is being done? (e.g., metal erection, shop, oil field, factory and industrial, agricultural, etc) 2. Does the applicant do any of the following types of work? ircraft or ircraft parts Yes No uto or vehicle welding Yes No Boiler and pressure vessel manufacturing or maintenance Yes No Oil field work Yes No Pipeline work Yes No efinery work Yes No Ship building operations Yes No ank work Yes No railer hitches Yes No 3. Does the applicant work only to customers specifications? Yes No 4. Does the applicant design, produce, or manufacture any product, part, machine, or device? Yes No 5. re records kept of all jobs? Yes No 6. Does the applicant subcontract any work? Yes No f Yes, how much? % 7. What are the applicant s estimated annual receipts? he pplicant, gent and/or Broker represents that the above statements and facts are true and that no material facts have been suppressed or misstated. Completion of this form does not bind coverage or commit the Company to policy issuance. ny person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. pplicant: Producer Signature: Date: Producer Signature: Weld 11/02

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