Synergy Coverage Solutions, LLC 217 S. Tryon Street Charlotte, NC 28202 www.synergyinsurance.net

T 704.927.2860 F 704.927.2867 info@synergyinsurance.net

Boat Manufacturers Supplemental Application

Name: _________________________________________________________________________________

Website: _______________________________________________________________________________

General information:

1) Hours of operation: ____________________________________________________________________

2) How many shifts do you have and what are the hours per shift?

3) Boats manufactured:

Max feet: _______________________________________________________

Number of boats sold per year: _____________________________________

Sales price range: $________________________ to $________________________

4) Are any sports teams sponsored by your company? Yes No

a) If yes, do any employees and/or officers participate? Yes No

5) All employees are required to wear (indicate with checkmark):

Safety glasses Other:

Hard hats

Steel toe shoes

Hearing protection

Gloves

6) Are all employees trained in proper lifting techniques? Yes No

7) Do you use any of the following materials-handling aids? (indicate with checkmark)

Forklifts

Dollies

Hand trucks

Hoists

Overhead cranes

8) Are employees trained in the safe operation of all the material-handling equipment used? Yes No

9) Do machines have proper ventilation/dust collection system? Yes No

10) Is there an OSHA compliant respiratory Protection Program in place? Yes No

11) Are lockout/tagout procedures in place? Yes No

12) Do you have an Early Return to Work program in place? Yes No

13) Do you have regular safety meetings with your employees? Yes No

Synergy Coverage Solutions, LLC 217 S. Tryon Street Charlotte, NC 28202 www.synergyinsurance.net

T 704.927.2860 F 704.927.2867 info@synergyinsurance.net

Fiberglass Application:

1) Are chopper guns used? Yes No

If yes:

Is emergency eyewash located in the fiberglass spraying area? Yes No

Are all employees required to use OSHA compliant respiratory protection? Yes No

Are all employees required to wear proper eye and face protective equipment? Yes No

Spray Painting Operations:

1) Do you have spray painting operations? Yes No

If yes:

Is your spray booth UL approved? Yes No

Are all employees required to use OSHA compliant respiratory protection? Yes No

Are all employees required to wear proper eye and face protective equipment? Yes No

Boat Testing:

1) What body of water are boats tested on? ___________________________________________________

2) Do your employees test boats on the water? Yes No

If yes:

How many times per year is boating done? ____________________________________________

What is the average length of boat tests (full day, one hour, etc.)? __________________________

How many employees are on board while a boat is being tested? __________________________

Do employees who test boats have a captains license? Yes No

What is the experience level of employees who test boats?

What form of communication do employees have when they are on the water (cell phone, radio,

etc.)? ___________________________________________________________________________

If no:

Who does your testing? ____________________________________________________________

Are certificates of insurance kept on file? Yes No

Synergy Coverage Solutions, LLC 217 S. Tryon Street Charlotte, NC 28202 www.synergyinsurance.net

T 704.927.2860 F 704.927.2867 info@synergyinsurance.net

Driving Exposure:

1) Do you deliver any boats? Yes No

2) Are common carriers or contract carriers used to deliver boats? Yes No

a) If yes, do you maintain certificates of insurance on all carriers who may deliver boats on your

behalf? Yes No

Employer Signature: ____________________________________________ Date: _________________