Metal Working / Machine Shop Questionnaire
This questionnaire is not an application for insurance and must be accompanied by a completed and signed ACORD
application.
Agency Name:
Applicant’s
Name:
Policy No.:
Applicant’s Web
Site:
Date Application Completed:
General Information
Explain metalworking or machine shop processes performed:
What is the average years of experience of your employees?
Describe any special training requirements for your employees:
Please provide a current year and prior year job listing. Please include the cost of each job, and indicate what industry is
served on each job (e.g. construction, lumber, etc.).
Occupancy Information
Are valuable or highly combustible materials used? (e.g. titanium or magnesium)
Yes
No
Yes
No
Provide a complete list of highly
combustible materials used:
How are these materials stored and disposed of
(and by whom)?
Is the local fire department equipped to handle a fire involving all materials used?
Are cutting fluids water soluble or oil based?
List all flammable liquids on premises, and describe how each are stored and
disposed of:
What is the approximate age of the machinery used in your business
and what is the expected life cycle for such machines?
Are any of the machines custom made, obsolete or irreplaceable?
Yes
No If yes, describe:
Describe any special hazards that exist in your operations: (e.g. welding, electroplating, heat
treating, painting, etc.)
Is all machinery properly guarded, shielded, and grounded?
Do all required personnel wear proper eye protection?
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IL 02 03 06
Yes
Yes
No
No
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Product Information
Please describe all proprietary products manufactured:
Please describe all products manufactured to the specifications of others:
Product Information (cont’d)
Do you perform any design work for your proprietary products?
Yes
No If Yes,
describe the design work you perform, and if not, please identify who performs such design
work:
Do you perform any design work for others?
customers and describe your process:
Yes
No If Yes, identify these
Do you have any discontinued operations/products or are you planning to have any
discontinued products/operations?
Yes
No If Yes, describe:
Are your products designed, tested, labeled and manufactured to meet
or exceed all applicable government and industry standards?
Yes
No If No, describe
Do you know all of the end users for all products you manufacture?
Are all designs reviewed, tested and verified?
whom?
Are designs or specifications ever changed?
change before implementation?
Yes
No
No If yes, by
Yes
Yes
Yes
No If yes, does the customer specify or approve the
No
Describe any off premises exposure, including, delivery, repair,
installation or assembly (and specify whether self performed or
subcontracted):
Do you have a written quality control program in place?
Who does the testing?
Insured
Yes
Customer
Can your products be identified from those of competitors?
No
Independent Laboratory or Vendor
Yes
No If yes, describe how:
Do you keep records of when each product was manufactured, who supplied the material, and to whom it was sold?
Yes
No
Have you ever recalled a product for any reason?
Yes
Do you have a written product recall plan in place?
Do you carry separate Products Liability coverage?
Yes
No If yes, describe:
Yes
No If yes, please provide a copy.
No If yes, please provide a copy of dec page.
Do you have a written procedure for handling customer complaints, accidents and injuries involving your
products?
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BMAG-METMACH-Q
Yes
No
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Who is responsible for handling customer complaints? Safety Manager?
Yes
No Management?
Yes
No
Do you perform any packaging, drafting of instructions or drafting of
warnings for any products you manufacture?
Yes
No If yes, please
describe:
Please add additional comments for any “Yes” answers above:
Product Information (cont’d)
Please list all products and attach a brochure for each product, if available:
Name of Product
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Projected Sales
$
$
$
$
$
$
$
$
$
$
End Use of Product
____________________________________________________________________________________________________
Completed By:_____________________________________
BMAG-METMACH-Q
AP IL 02 03 06
Date:_____________________________
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