Manufacturers

GENERAL INFORMATION
Named Insured:*
Phone:*
Company Contact:
Phone:
Street Address:
P.O. Box:
County:
City, State, Zip Code:
Coverage effective dates:
From:
To:
Location Name and Address:
Additional subsidiaries & descriptions: if any
Number of years in business:
Member of NTMA?

NoYes
Chapter:
Annual Gross Sales:
Employees:
Shifts:
Is the general public allowed on the premises?

YesNo
Work Product is sold to:

commercial customers orgeneral public
Work Product is sold:

within US/Canadaoutside US/Canada, orboth
Final End Product is Sold to:

commercial customersgeneral public, orUnknown
Does Insured design & market completed products:

YesNo
Under private label

YesNo
List completed product(s)
Component Parts only?

YesNo
Any assembly included?

YesNo
Is Insured a Job Shop (products designed by others)

YesNo
Design Assist

YesNo
What percentage of operations is to the specifications of the customer?
Has the insured purchase any operations in the past ten years?

YesNo
Does the insured have any discontinued products they sold?

YesNo
Does the insured have any discontinued operations?

YesNo
Has the insured received any OSHA violations in the last 3 years?

YesNo
Does the insured have any open citations?

YesNo
If yes, how are they addressing the recommendation?
Has the Insured had any Property or Liability Claims in the past 5 years?

YesNo
Any Work Subcontracted Out:

YesNo
Are Certificates of Insurance Obtained?

YesNo
List Operation(s)
Was this building originally designed and constructed for Current Operations?

YesNo
If no, what was the original building occupancy?
If applicable, what year was the building retrofitted for use as a mfg. facility?

Building inspected or updated?

	Electric	Heating	Heating	Roof
Qualified Inspection
Installed, Replaced or Updated

Is there an Automatic Fire Sprinkler System installed in all buildings?

YesNo
How often is the sprinkler system tested?
Date of last test?
Sprinkler:

Early Suppression (ESFR)Hydraulically CalculatedPipe SchedUnknown
Installed original with the building?

YesNo
Is there an auxiliary electrical supply system?

YesNo
Is there an emergency lighting system?

YesNo
Is there a Central Station Burglar Alarm System

YesNo
Is there a Central Station Fire Alarm System

YesNo
Cutting Oils:

Petroleum BasedWater BasedBothNot Applicable
Use of Flammables/Chemicals/Solvents?

YesNo
Separate UL approved Storage

YesNo
Does the insured maintain premises adequately?
Inside

YesNo
Outside

YesNo
Are insured’s premises fenced, or access to the location limited?

YesNo
Where is scrap/stock stored?

InsideOutsideBoth
Is the property fenced?

YesNo
Is the property lighted?

YesNo
Security Guard?

YesNo
Does insured back up all software, including computer operated machines, on a regular basis?

YesNo
if so how often?
Does the insured have a vehicle maintenance program?

YesNo
Check all that apply to the Insured’s Employee Safety Program

Back to Work ProgramMandatory Personal Protective EquipmentRegular Safety MeetingsAccident InvestigationSafety Committee/OfficerSupervisor TrainingMaterial Handling ProceduresNew Hire TrainingLock Out/Tag OutProactive Management
Is All Work Inspected/Quality Controlled?

YesNo
Is There a Formalized Rejection and Tracking Process

YesNo
Is the Line Card/Equipment List available on the company’s Website?

YesNo
Ventilation/Duct System/Air Handling?
Current System(s) (check all that apply):

DustSmokeMistFumeIndustrialOther
How often inspected?

MonthlyAnnuallyOn ServiceUnknownOther
How often cleaned?

MonthlyAnnuallyOn ServiceUnknownOther
Are there scrubbing filters for discharge to outside air?

YesNoUnknown
Is there a formal Fire Safety Training Program?

YesNo
Contact Person in charge of Fire Safety:
Outline Protective Safeguards for Employees from hot machinery and/or Materials:
COMMENTS/DESCRIPTION OF OPERATIONS:
Should be Empty:

GENERAL INFORMATION