Insurance For Welders

Liability Renewal Application

LRA

Current Limit of Liability Carried:

Current Description of Operations: Shop & Mobile Welding Including Pipeline/Pressure

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

= 100%

= 100%

= 100%

When requesting over $2,000,000.00 CGL, please complete the following information in as much detail as possible.
Consent & 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 Broke

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.