Accountfirst Welding Supplemental Risk Questionnaire
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1Welding Supplemental Risk Questionnaire
1.
Company name:
2.
Street address:
City, state, zip:
Select State
3.
Does your company manufacture or distribute welding rod, wire, equipment or accessories?
Yes
No
4.
Does your company manufacture or distribute exhaust systems or personal protective equipment or
accessories for welders?
Yes
No
5.
Is welding performed on premises?
Yes
No
6.
Payroll and premium information for the current year and last three (3) years:
Year
Payroll
Premium
Current:
1
Prior:
st
2
Prior:
nd
3
Prior:
rd
7.
Is welding operation:
Routine production
In con ned areas
Maintenance/repairs
Remote/isolated
8.
Frequency of welding operation:
Daily
Weekly
Monthly
Quarterly
9.
How many employees or contractors working on or in proximity of welding tasks?
Less than three (3)
Four (4) to ten (10)
Greater than ten (10)
10.
Are there any currently-owned or divested subsidiaries that manufactured or sold welding rods or equipment,
or protection systems for airborne respirable welding fumes?
Yes
No
11.
Do you have controls in place to control employee exposure (i.e. exhaust ventilation, respirators, welding
curtains, gloves, aprons or helmets)?
Yes
No
12.
Have you ever performed an Industrial Hygiene Survey for welding fumes?
Yes
No
To the best of my knowledge, all of the information I have given about my business is true and correct.
O˜c er or Owner of Business
Date
1851 University Blvd. South, Jacksonville, FL 32216 | P 1.800.214.9789 | F 904.721.1198
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