COMMERCIAL AUTO AND GARAGE SUPPLEMENTARY APPLICATION

Section 1: APPLICANT INFORMATION

Company name (Name Insured):

Applicant’s Legal Name: *

First

Last

Effective Date of Coverage :

Mailing Address

City

County

State

Zip

IF OTHER please describe:

Years in Business:

Owner's Name *

First

Last

Federal ID Number OR SS#:

Inspection Contact:

Phone:

Section 2: LOCATION INFORMATION

Number

St,City,County,State,Zip

Use of Loc./How Occupied

Number

St,City,County,State,Zip

Use of Loc./How Occupied

Number

St,City,County,State,Zip

Use of Loc./How Occupied

Number

St,City,County,State,Zip

Use of Loc./How Occupied

Section 3: Auto Liability Coverage:

1. Limit:

$300,000
$500,000
$750,000
$1,000,000 (Combined Single Limits)

No Fault /Personal Injury Protection:

Property Protection (Michigan only)

Medical Payments

Uninsured Motorist

Underinsured Motorist (Same Limit as Uninsured Motorist)

Hired Car
Non-Owned Auto

6. Dealer/Transporter Tags: How Many?

Tag Number:

7. Describe the use for each tag

Please follow the instruction listed below for additional coverage:

Please follow the instruction listed below for additional coverage: (copy)

Please follow the instruction listed below for additional coverage: (copy) (copy)

Total Gross Annual Sales:

Section 4: Operational Revenue:

Operation - Percentage of Revenue

Complete Section

Towing :

Towing : Percentage of Revenue %

Complete Section

Voluntary Repossession : Percentage of Revenue %

Complete Section

Involuntary Repossession : Percentage of Revenue %

Complete Section

Auto Transporting (car haulers) : Percentage of Revenue %

Complete Section

Trucking/Equipment Hauling : Percentage of Revenue %

Complete Section

Trucking/Other : Percentage of Revenue %

Complete Section

Please state Other Trucking Operation here :

Repair Shop : Percentage of Revenue %

Complete Section

Body Shop Repairs : Percentage of Revenue %

Complete Section

Service Station : Percentage of Revenue %

Complete Section

Rental Operations : Percentage of Revenue %

Complete Section

Salvage/Used part sales : Percentage of Revenue %

Complete Section

Tire Sales : New %

Tire Sales : Used %

Tire Sales : Recapped %

Gross Sales:

Fire Works Sales/Storage : Percentage of Revenue %

Complete Section

Lien Car Sales : Percentage of Revenue %

Complete Section : Number of cars sold per month:

Number of cars sold per month:

Auctions : Percentage of Revenue %

Complete Section : Number held annually

Number held annually

Part Sales – New : Percentage of Revenue %

Parking/Storage : Percentage of Revenue %

Other : Percentage of Revenue %

Complete Section : IF Other please specify:

IF Other please specify:

Financial History: In the past three years has the company or its owners filed for bankruptcy, financial reorganization or had any liens placed against it

Section 5: Safety Management:

1. Name and Title of person in charge of the Safety Program

2. Do you have a Written Safety Program?

3. How often do you hold safety meetings?

Weekly
Monthly
Quarterly

4. Are ALL trucks equipped with annually inspected fire extinguishers?

5. Do you have a written Driver Training Program?

6. Do you have a written vehicle take-home policy?

7. Do you have a drug-testing program in place?

Section 6: Maintenance:

1. Do you maintain maintenance logs on each vehicle?

2. Do you perform the routine maintenance on your equipment?

3. If YOU DO NOT perform the maintenance who does?

4. Are they Professionally Certified as Mechanics?

5. Are your drivers in any way responsible for the cost of the maintenance of your equipment?

6. Do your drivers perform daily maintenance checks on ALL vehicles?

7. Are your vehicles subject to ANNUAL INSPECTION by the STATE?

Section 7: Driver Management Section:

1. Pre-hire Screening: Do you obtain a Motor Vehicle Record Report (MVR) on each driver prior to hiring?

2. Do you require job references?

3. Do you check job references prior to hiring?

4. Do you road test ALL drivers prior to hiring?

5. Driver Management: Do you obtain an MVR on ALL company drivers at least on an Annual basis?

6. Do you maintain driver files on ALL drivers including copies of tickets and the MVR?

7. Do ALL your drivers meet the federal, state and local license classification requirements?

8. Do you have a Written Disciplinary/Termination policy?

9. Do you have a Written Accident Review Policy?

10. Do you issue any employee or independent contractor a 1099?

11. Do you carry Workers Compensation Insurance for ALL your employees?

12. How are drivers compensated?

Hourly Wage
Salary
Commission
1099

13. How many drivers quit or were fired last year?

How many did you hire last year?

14. Do you require your drivers to take outside training courses?

15. If yes, what driver training do you provide for your drivers?

Section 8: General Operations:

1. Operations: Do you lease vehicles from other individuals or companies?

2. Do you lease vehicles to other individuals or companies?

3. Do you own or lease any cranes?

4. Do you hire SUB-CONTRACTORS at any time?

5. Do you have any additional vehicles owned or leased by your company NOT on this schedule?

6. Do your vehicles travel outside of a 200-mile radius on a Regular basis?

7. Are the following procedures or items required?

8. Do you require the use safety chains on every tow?

9. Do you require the use of wheel-lift straps on every tow?

10. Do you require the use of vehicle-towing lights on every tow?

11. Please breakout the per trip mileage for your fleet: 0-50 Miles

51-200 Miles %

Over201 Miles %

Section 9: Regulatory Filings:

(To aid in the processing of a filing please submit a copy of the prior filing we are replacing)

1. Filings: Do you require a DOT or State Filing?

2. Do you require an MCS-90 endorsement?

3. Haz Mats: Do you ever perform secondary tows of hazardous materials?

4. Do you ever move hazardous materials on a primary haul basis?

5. MC/DOT NUMBER:

STATE DOCKET NUMBER:

6. Are any additional filings required?

Section 10: GENERAL LIABILITY:

(Same limit applies to all locations) (Aggregate limit is 1, 2, or 3 times the Occurrence limit)

1. Occurrence Limit:

$300,000
$500,000
$750,000
$1,000,000

Aggregate Limit:

Location 1: General Liability Section:

Complete the following for all operations: Amounts are for Gross annual only

1. Trucker/Towing : Gross Payroll

2. Auto Repair and Body Shops (10073) : Gross Sales

3. Roadside Assistance (10073) Add sales to Auto repair if there is a shop : Gross Sales

4. Parking/Storage (46622) Storage area including inside Garage) : Storage Area

5. Parking/Storage (46604) (use this code if a storage charge is made) : Gross Sales

6. Buildings/Office (applies if no storage or repair) : Square Feet

7. Vacant Building (68606) : Square Feet

8. Vacant Land (49451) : Square Feet

9. Stores (13673) If any cooking submit with Restaurant supplement : Gross Sales

10. Gasoline Stations _ Self Service (13454) : Annual Gallons

11. Gasoline Stations _ Full Service (13453) : Annual Gallons

12. Tire Dealer (18616) If installed only add sales to auto repair : Gross Sales

13. Auctions (91179) Lien car sales : Gross Payroll

14. Auto Dismantling/Salvage (91190) : Gross Payroll

15. Other: Please Specify

Rating Basis:

Location 2: General Liability Section:

Complete the following for all operations: Amounts are for Gross annual only

1. Trucker/Towing : Gross Payroll

2. Auto Repair and Body Shops (10073) : Gross Sales

3. Roadside Assistance (10073) Add sales to Auto repair if there is a shop : Gross Sales

4. Parking/Storage (46622) Storage area including inside Garage) : Storage Area

5. Parking/Storage (46604) (use this code if a storage charge is made) : Gross Sales

6. Buildings/Office (applies if no storage or repair) : Square Feet

7. Vacant Building (68606) : Square Feet

8. Vacant Land (49451) : Square Feet

9. Stores (13673) If any cooking submit with Restaurant supplement : Gross Sales

10. Gasoline Stations _ Self Service (13454) : Annual Gallons

11. Gasoline Stations _ Full Service (13453) : Annual Gallons

12. Tire Dealer (18616) If installed only add sales to auto repair : Gross Sales

14. Auto Dismantling/Salvage (91190) : Gross Payroll

15. Other: Please Specify

Rating Basis:

Location 3: General Liability Section:

Complete the following for all operations: Amounts are for Gross annual only

1. Trucker/Towing : Gross Payroll

2. Auto Repair and Body Shops (10073) : Gross Sales

3. Roadside Assistance (10073) Add sales to Auto repair if there is a shop : Gross Sales

4. Parking/Storage (46622) Storage area including inside Garage) : Storage Area

5. Parking/Storage (46604) (use this code if a storage charge is made) : Gross Sales

6. Buildings/Office (applies if no storage or repair) : Square Feet

7. Vacant Building (68606) : Square Feet

8. Vacant Land (49451) : Square Feet

9. Stores (13673) If any cooking submit with Restaurant supplement : Gross Sales

10. Gasoline Stations _ Self Service (13454) : Annual Gallons

11. Gasoline Stations _ Full Service (13453) : Annual Gallons

12. Tire Dealer (18616) If installed only add sales to auto repair : Gross Sales

13. Auctions (91179) Lien car sales : Gross Payroll

14. Auto Dismantling/Salvage (91190) : Gross Payroll

15. Other: Please Specify

Rating Basis:

Section 11: Garage Keepers Coverage:

Please provide the details of each storage facility.

1. Coverage Type:

Legal Liability
Direct Primary (available only if required by contract – attach copy)

Loc.1. Limit: $

Address:

City:

State:

Zip

Loc.2. Limit: $

Address:

City:

State:

Zip

Loc.3. Limit: $

Address:

City:

State:

Zip

2. Do you provide public parking or storage at any of you locations?

Loc 1

Loc 2

Loc 3

3. Completely fenced

Loc 1

Loc 2

Loc 3

4. Completely lighted at night

Loc 1

Loc 2

Loc 3

5. Surveillance camera equipped

Loc 1

Loc 2

Loc 3

6. Is the facility equipped with Intrusion alarm?

Loc 1

Loc 2

Loc 3

7. Lot attended during business hours

Loc 1

Loc 2

Loc 3

8. ARMED Security guards on duty during the day or at night?

Loc 1

Loc 2

Loc 3

9. Fire extinguishers are accessible at each yard

Loc 1

Loc 2

Loc 3

10. Customers’ keys are kept locked in a secure location

Loc 1

Loc 2

Loc 3

Garage Keepers Operations:

11. Do you pick up or deliver customers’ vehicles by driving the vehicle?

Loc 1

Loc 2

Loc 3

12. Do you maintain the proper type and number of fire extinguishers?

Loc 1

Loc 2

Loc 3

Section 12: Towing

1. How many tows do you perform on average per month?

2. How many employees are involved in this operation?

3. Indicate below the various types of towing you perform:

4. Private Property (illegal parking violator removal)

5. Municipality, Highway or Turnpike Rotation

6. Voluntary Repossessions

7. Heavy Duty Commercial Towing and Recovery

8. Motor Club towing

9. Towing for banks or finance companies

10.Towing for your own garage/body shop

11. Involuntary Repossessions

Dispatching:

12. Are your tow trucks equipped with Scanners?

13. Do you participate in any “Chase” or first on the Scene towing?

14. Do you require each tow performed by your company to be dispatched by your office dispatcher?

Section 13: Rental Operations:

Please provide the details of this operation in a narrative on the remarks page.

1. Do you operate a Rental or Leasing operation at any location scheduled on this policy?

2. Do you have a general liability policy in place covering this operation?

Section 14: Service Station Operations

Please provide the details of this operation in a narrative presented with this application.

1. Do you have a general liability policy in place covering this operation?

2. Do you have underground gas storage?

3. Do you maintain pollution coverage on all storage tanks above ground and/or below ground?

4. Do you sell Alcoholic Beverages?

Section 15: Voluntary and Involuntary Repossession

Please provide the details of this operation in a narrative presented with this application.

1. Who issues the assignment to pick up a car?

2. Are the debtors’ notified in advance and agreeable to the voluntary surrender of the vehicles?

3. Do you perform Involuntary Repossessions?

4. If Repo sales are more than 15% of total sales:

Section 16: Salvage, Dismantlers Scrap Metal or Junkyard

Provide the details of this operation on the remarks page.

1. Do you have a General Liability Policy in place covering this operation?

Loc 1

Loc 2

Loc 3

2. Do you or have you ever owned or leased a crushing machine?

Loc 1

Loc 2

Loc 3

3. Do you allow third party vendors to perform crushing on your property?

Loc 1

Loc 2

Loc 3

4. Do you allow customers to pull parts from the stored autos?

Loc 1

Loc 2

Loc 3

5. Do you retain a copy of the sales receipt for all parts sold?

Loc 1

Loc 2

Loc 3

6. Does your receipt contain a “Sold as is Warranty”?

Loc 1

Loc 2

Loc 3

7. How many employees do you have involved in this operation?

Loc 1

#of Employees

Loc 2

#of Employees

Loc 3

#of Employees

*** Please provide a SAMPLE COPY of a receipt with the “SOLD AS IS WARRANTY” wording with this application

Section 17: Auto Transporting/Car Hauling

List all Destinations Regularly or frequently traveled or attach copies of last two quarters of IFTAs

Any Freight Brokering?

Use Trailer Interchange Agreements?

Any drive-away work?

Any transporter plates?

Any vehicle leased/loaned/rented to others?

Any employees/owner operators not listed?

Any owned/leased vehicles not listed?

Haul Boats?

Haul Campers/Mtr Homes?

Haul other Freight?

Auto Dealer?

Auto Repair/Body Shop?

Own or sponsor a car for racing?

Storage Lot/Terminal?

Truckers Payroll (Excluding Drivers) (If none show state minimum)

Section 18: Truck/Equipment Hauling

Please provide the details of this operation in a narrative presented with this application.

1. Do you have contracts to haul goods for specific customers?

2. Are all drivers performing this work CDL Class “A” licensed drivers?

3. Do you haul, transport or set up Mobile Homes?

4. What is the MAXIMUM distance traveled? ___ Miles

Miles

5. How many of your drivers are involved in this operation?

6. What commodities do you haul?

Section 19: Service Garage / Auto Repairs:

Location 1, 2 & 3

Annual Gross Sales:

1. Do you sell auto parts?

NEW
USED

Loc 1

Loc 2

Loc 3

2. Do you sell “third party” remanufactured parts?

Loc 1

Loc 2

Loc 3

3. Does your sales receipt contain a “Sold, as is Warranty”

Loc 1

Loc 2

Loc 3

4. Do you sell and install tires?

NEW
USED

Loc 1

Loc 2

Loc 3

5. Do you sell recapped tires for private or commercial vehicles?

Loc 1

Loc 2

Loc 3

6. Do you perform any type of welding at any location?

Loc 1

Loc 2

Loc 3

7. Do you have any dogs on your premises during or after hours?

Loc 1

Loc 2

Loc 3

8. Do you have gas sales at any location scheduled on this policy?

Loc 1

Loc 2

Loc 3

9. Are there above ground and/or below ground storage tanks at any location?

Loc 1

Loc 2

Loc 3

10. Do you own or lease out limousines, vans or buses?

Loc 1

Loc 2

Loc 3

11. Do you own or operate a car wash at any location?

Loc 1

Loc 2

Loc 3

12. Do you restrict the public from entering your garage work area?

Loc 1

Loc 2

Loc 3

13. Do you provide an area for customers to wait while their vehicle is repaired?

Loc 1

Loc 2

Loc 3

14. Do you operate a convenience store at any location?

Loc 1

Loc 2

Loc 3

15. Is the facility inspected by a governmental agency on an annual basis?

Loc 1

Loc 2

Loc 3

16. Do you retain written records on all repairs performed by your operation?

Loc 1

Loc 2

Loc 3

17. Are repairs performed on private passenger autos?

Loc 1

Loc 2

Loc 3

18. Are repairs performed on commercial autos or heavy equipment?

Loc 1

Loc 2

Loc 3

19. Do you own, sponsor or work on “race cars”?

Loc 1

Loc any drivers

Loc 2

Loc 3

20. Are ALL of your service and repair mechanics professionally certified?

Loc 1

Loc 2

Loc 3

21. How many mechanics do you have working at each location?

Loc 1

#of Mechanics

Loc 2

#of Mechanics

Loc 3

#of Mechanics

22. What types of repairs do you perform?

Minor Repairs
Major Repairs (Rebuild Engines, Transmission)

23. What types of vehicles do you repair

Private Passenger
Commercial Auto
Commercial Equipment

24. How many service bays do you have?

How many of those bays have a lift system for hoisting automobiles?

26. Please indicate if you sell or service any of the following

Sell
Service

ATV's

Motorcycles

Gray Market Vehicles

Boats

Kit Cars

RV’s

Van Conversion

Stretch Vehicles

Section 20: Service Garage / Auto Body Shop

Location 1, 2 & 3

1. Do you have a paint booth?

Loc 1

Loc 2

Loc 3

2. Do you have a UL approved Paint Booth?

Loc 1

Loc 2

Loc 3

3. Do you paint cars outside of the booth?

Loc 1

Loc 2

Loc 3

4. Do you perform welding as part of the repair?

Loc 1

Loc 2

Loc 3

5. Do you have a frame-straightening machine?

Loc 1

Loc 2

Loc 3

6. How many employees do you have involved in this operation?

Loc 1

#of Employee

Loc 2

#of Employee

Loc 3

#of Employee

7. What company manufactured the Frame Straightening Machine?

Driver Information : Applicant

Complete the information below for ALL DRIVERS

Driver #1 : Name

First

Last

DOB

Drivers License Number

Years Exp

Hire Date

Driving Record

Driver #2 : Name

First

Last

DOB

Drivers License Number

Years Exp

Hire Date

Driving Record

Driver #3 : Name

First

Last

DOB

Drivers License Number

Years Exp

Hire Date

Driving Record

Driver #4 : Name

First

Last

DOB

Drivers License Number

Years Exp

Hire Date

Driving Record

Driver #5 : Name

First

Last

DOB

Drivers License Number

Years Exp

Hire Date

Driving Record

Has every possible driver been identified including part time?

VEHICLE SCHEDULE : ISO radius applies: 50 miles; 200 miles; Long distance (for long distance we need all destinations).

ISO radius applies: 50 miles; 200 miles; Long distance (for long distance we need all destinations).

Vehicle

Cost New

Vehicle Identification number