Insurance Safety Application

INSURANCE SAFETY APPLICATION

This Insurance Safety Application (the "Application") is submitted to assist the insurer in evaluating safety practices, exposures and underwriting considerations related to the requested coverage. The applicant certifies that the information provided is true, complete and accurate to the best of the applicant's knowledge. Material misrepresentations may result in declination, rescission or adjustment of coverage and premium.

APPLICANT / INSURED INFORMATION

Individual    Corporation    LLC    Partnership    Other:

POLICY DETAILS

SAFETY PROGRAM SUMMARY

Does the organization maintain a written safety program?    Yes    No

WORKPLACE HAZARDS & CONTROLS

Indicate which recognized hazards are present at the primary location (check all that apply):

Fall protection    Confined space entry    Lockout/tagout    Respiratory hazards

Chemical hazards    Electrical hazards    Vehicle operations    Hot work (welding, cutting)

EQUIPMENT MAINTENANCE & INSPECTION

Is there a documented equipment maintenance and inspection program?    Yes    No

TRAINING & CERTIFICATIONS

Indicate applicable training and certification programs provided to employees:

PPE training    First aid / CPR    Drug testing program    Certified equipment inspectors

LOSS HISTORY

BENEFICIARY DESIGNATION

If applicable to the requested coverage, designate beneficiary(ies). Percentages must total 100%.

DOCUMENTATION CHECKLIST

Provide the following documents where applicable (check boxes for each included attachment).

Safety manual    Training records (last 12 months)    Inspection reports (last 12 months)

Equipment maintenance logs    Loss runs (last 5 years)    Drug testing policy

EXCLUSIONS & ACKNOWLEDGEMENTS

The applicant acknowledges that standard policy exclusions apply unless otherwise negotiated in writing. Such exclusions commonly include but are not limited to: intentional acts, punitive damages, war risks, nuclear hazards and pollution not specifically endorsed. The applicant expressly authorizes the insurer or its representatives to inspect premises, safety programs and records as necessary for underwriting and claims investigation.

Applicant acknowledges standard exclusions and authorizes inspections.

DECLARATION AND CERTIFICATION

By signing below, the applicant declares that all information contained in this Application and any attachments is complete and accurate. The applicant understands that this Application is part of the insurance policy application and that any material misstatement, omission or concealment may void coverage or be grounds for rescission. The applicant further certifies that no person completing this form has knowledge of any circumstance that would render the above statements incomplete or inaccurate.

The applicant agrees to promptly report material changes to operations, exposures, safety practices or loss experience that occur prior to policy inception or renewal and acknowledges that underwriting decisions and premiums will be based on the information provided.

SIGNATURE

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