New Welders Application
General Information

1.

3. Mailing Address

4. Contact Information

5.

6.

Experience

2. Employment History

Please report all previous employment - describe the type of welding performed and length of employment. This section can be omitted if you attach a copy of your resume
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3. Qualifications

**Please provide copies of all certifications**
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Maximum upload size: 67.11MB
Operations

1. Please provide the percentage of work done in each of the following categories:

+

= 100%

+

= 100%

+

= 100%

3. Please indicate if work is done on any of the following & include percentages for each:

5. Employees

Loss Control
1.
Quality Control

Claims History

Equipment List [valued over $1,000 per item]:

Miscellaneous Tools [valued under $1,000 for any one limit, pair, or set]:

Authorization

Please list all individuals that you authorize to act on your behalf:

CONSENT AND DISCLOSURE:
The parties acknowledge that the Broker is being retained by the Client to acquire or renew a policy or policies of insurance for the Client, under which certain individuals, including the Client's employees, servants, agents and representatives may be insured (hereinafter called "insured individuals"). Accordingly, each of the parties may need to collect, use and disclose the personal information of such insured individuals.
FOR GOOD AND VALUABLE CONSIDERATION, the receipt and sufficiency of which is hereby acknowledged, each of the parties hereto agrees to collect, use and disclose the personal information of such insured individuals in a manner that a reasonable person would consider appropriate in the circumstances. Each of the parties further agrees to safeguard the security of such personal information in a manner appropriate to the sensitivity of that information.
FOR THE SAID CONSIDERATION, the Client further covenants and warrants that the Client has obtained the appropriate consent from such insured individuals to disclose their personal information to the Broker.
THE ATTENTION OF THE SIGNATORY IS DRAWN TO STATUTORY CONDITION #1 OF THE POLICY, WHICH READS AS FOLLOWS: MISREPRESENTATION
If any person applying for insurance falsely describes the property to the prejudice of the Insurer, or misrepresents or fraudulently omits to communicate any circumstance which is material to be made known to the Insurer in order to enable it to judge of the risk to be undertaken, the contract shall be void as to any property in relation to which the misrepresentation or omission is material.