Applicant's Name

First Last

Applicant Mailing Address

Applicant's Phone Number

Proposed Policy Period

From To

Applicant is:

Individual

Partnership

Corporation

Joint Venture

Other

How long has this applicant been in business?

HARD GOOD SALE

Welding Supplies

$

Medical Equipment or Supplies

$

Cylinder Rental

$

Total Hard Good Sales

$

GAS SALES

Medical Gas Sales

$

Aviation Gas Sales

$

All Other Gas Sales

$

Total Gas Gross Annual Sales

$

Note:

In addition to the above gas sales, complete the attached Gas Volume Chart.

ACETYLENE GAS MANUFACTURING

Total Gross Sales

$

GROSS SALES FROM INSTALLATION SERVICE OR REPAIR OF EQUIPMENT

DESCRIPTION OF OPERATIONS

PAYROLL

$

SALES

$

RENTAL SALES (OTHER THAN CYLINDER)

Total Gross Sales from all rentals

$

OFF PREMISES SERVICES

Do you deliver products or equipment?

Yes

No

Do you deliver propane?

Yes

No

Do you maintain commercial automobile liability coverage?

Yes

No

POISONOUS GASES

List any class of poisonous gases you sell or distribute, trans-fill, or transport.

PRODUCT NAME

TRANS-FILL METHOD

TRANSPORT

Yes

No

Prior Policy

Prior Policy Date

_______ to ________

Carrier Name

Coverage Type: Liab/PHD/MTC

POLICY #

# of Units Insured

Any loses within the past 5 years?

If YES please upload on the related documents attaching box below.

Amount Paid

Upload Your Current Insurance Policy or Related Documents

Drop files here or

Max. file size: 20 MB, Max. files: 10.

How did you here us?

IMPORTANT NOTICE

As part of our underwriting procedure, a routine inquiry may be made to obtain applicable information concerning character, general reputation, personal characteristics, and mode of living. Upon written request, additional information as to the nature and scope of the report, if one is made, will be provided.

FRAUD STATEMENT

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison