GENERAL INFORMATION

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* Please also indicate your preferred method of contact


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EXPERIENCE

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Please report all previous employment - describe the type of Welding Performed and Length of Employment.

DATE (FROM - TO) COMPANY AREA DESCRIBE TYPE OF WELDING PERFORMED
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OPERATIONS

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Please indicate with either a "Yes" or a "No" if you weld in any of the following areas


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LOSS CONTROL

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AUTOMOBILE - **NOTE Only complete if Automobile coverage is required

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FULL NAME BIRTH DATE LICENSE NO. & PROVINCE YEARS LICENSED ACCIDENTS & CONVICTION DATES & DETAILS SIGNATURE (use mouse to sign)
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YEAR MAKE MODEL YEARS LICENSED SERIAL NUMBER WELDING TRUCK

CONTRACTORS EUIPMENT AND TOOLS

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DESCRIPTION OF EQUIPMENT YEAR SERIAL NUMBER SUM INSURED

****NOTE: For Miscellaneous Tools, provide the total of all the tools under the value of $1000 per item, pair or set. Tools valued at Over $1000 per item pair or set should be listed under Contractors Equipment

CLAIMS HISTORY

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DATE DESCRIPTION OF LOSS PAYMENT

AUTHORIZATION

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