SUPPLEMENTAL APPLICATION – COMMERCIAL AUTO AND GARAGE

Thank you!

NEXT: PLEASE FILL OUT THE SUPPLEMENTARY APPLICATION BELOW

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
Business type:
Individual
Corp.
LLC
Partnership
Joint Venture
Other
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)
2.
No Fault /Personal Injury Protection:
$
.
Property Protection (Michigan only)
$
3.
Medical Payments
$
4.
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)
Please follow the instruction listed below for additional coverage: (copy) (copy)Miscellaneous Towing and Recovery Equipment Coverage: Provide a separate schedule of the items to be covered; the list should include serial numbers, value and deductible for each item to be covered. (The minimum deductible is $500.)
Total Gross Annual Sales:
Section 4: Operational Revenue:
Operation - Percentage of Revenue
Complete Section
Towing :
Towing : Percentage of Revenue %
Complete Section
Complete Section
Voluntary Repossession : Percentage of Revenue %
Voluntary Repossession : Percentage of Revenue %
Complete Section
Complete Section
Involuntary Repossession : Percentage of Revenue %
Involuntary Repossession : Percentage of Revenue %
Complete Section
Complete Section
Auto Transporting (car haulers) : Percentage of Revenue %
Auto Transporting (car haulers) : Percentage of Revenue %
Complete Section
Complete Section
Trucking/Equipment Hauling : Percentage of Revenue %
Trucking/Equipment Hauling : Percentage of Revenue %
Complete Section
Complete Section
Trucking/Other : Percentage of Revenue %
Trucking/Other : Percentage of Revenue %
Complete Section
Complete Section
Please state Other Trucking Operation here :
Repair Shop : Percentage of Revenue %
Repair Shop : Percentage of Revenue %
Complete Section
Complete Section
Body Shop Repairs : Percentage of Revenue %
Body Shop Repairs : Percentage of Revenue %
Complete Section
Complete Section
Service Station : Percentage of Revenue %
Service Station : Percentage of Revenue %
Complete Section
Complete Section
Rental Operations : Percentage of Revenue %
Rental Operations : Percentage of Revenue %
Complete Section
Complete Section
Salvage/Used part sales : Percentage of Revenue %
Salvage/Used part sales : Percentage of Revenue %
Complete Section
Complete Section
Tire Sales : New %
Tire Sales : New %
Tire Sales : Used %
Tire Sales : Used %
Tire Sales : Recapped %
Tire Sales : Recapped %
Gross Sales:
Gross Sales:
Fire Works Sales/Storage : Percentage of Revenue %
Fire Works Sales/Storage : Percentage of Revenue %
Complete Section
Complete Section
Lien Car Sales : Percentage of Revenue %
Lien Car Sales : Percentage of Revenue %
Complete Section : Number of cars sold per month:
Number of cars sold per month:
Auctions : Percentage of Revenue %
Auctions : Percentage of Revenue %
Complete Section : Number held annually
Number held annually
Part Sales – New : Percentage of Revenue %
Part Sales – New : Percentage of Revenue %
Parking/Storage : Percentage of Revenue %
Parking/Storage : Percentage of Revenue %
Other : 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
YES
NO
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
YES
NO
Section 5: Safety Management:
1. Name and Title of person in charge of the Safety Program
2. Do you have a Written Safety Program?
YES
NO
3. How often do you hold safety meetings?
Weekly
Monthly
Quarterly
4. Are ALL trucks equipped with annually inspected fire extinguishers?
YES
NO
5. Do you have a written Driver Training Program?
YES
NO
6. Do you have a written vehicle take-home policy?
YES
NO
7. Do you have a drug-testing program in place?
YES
NO
Section 6: Maintenance:
1. Do you maintain maintenance logs on each vehicle?
YES
NO
2. Do you perform the routine maintenance on your equipment?
YES
NO
3. If YOU DO NOT perform the maintenance who does?
4. Are they Professionally Certified as Mechanics?
YES
NO
5. Are your drivers in any way responsible for the cost of the maintenance of your equipment?
YES
NO
6. Do your drivers perform daily maintenance checks on ALL vehicles?
YES
NO
7. Are your vehicles subject to ANNUAL INSPECTION by the STATE?
YES
NO
Section 7: Driver Management Section:
1. Pre-hire Screening: Do you obtain a Motor Vehicle Record Report (MVR) on each driver prior to hiring?
YES
NO
2. Do you require job references?
YES
NO
3. Do you check job references prior to hiring?
YES
NO
4. Do you road test ALL drivers prior to hiring?
YES
NO
5. Driver Management: Do you obtain an MVR on ALL company drivers at least on an Annual basis?
YES
NO
6. Do you maintain driver files on ALL drivers including copies of tickets and the MVR?
YES
NO
7. Do ALL your drivers meet the federal, state and local license classification requirements?
YES
NO
8. Do you have a Written Disciplinary/Termination policy?
YES
NO
9. Do you have a Written Accident Review Policy?
YES
NO
10. Do you issue any employee or independent contractor a 1099?
YES
NO
11. Do you carry Workers Compensation Insurance for ALL your employees?
YES
NO
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?
YES
NO
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?
YES
NO
2. Do you lease vehicles to other individuals or companies?
YES
NO
3. Do you own or lease any cranes?
YES
NO
4. Do you hire SUB-CONTRACTORS at any time?
YES
NO
5. Do you have any additional vehicles owned or leased by your company NOT on this schedule?
YES
NO
6. Do your vehicles travel outside of a 200-mile radius on a Regular basis?
YES
NO
7. Are the following procedures or items required?
8. Do you require the use safety chains on every tow?
YES
NO
9. Do you require the use of wheel-lift straps on every tow?
YES
NO
10. Do you require the use of vehicle-towing lights on every tow?
YES
NO
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?
YES
NO
2. Do you require an MCS-90 endorsement?
YES
NO
3. Haz Mats: Do you ever perform secondary tows of hazardous materials?
YES
NO
4. Do you ever move hazardous materials on a primary haul basis?
YES
NO
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
YES
NO
Loc 2
YES
NO
Loc 3
YES
NO
3. Completely fenced
Loc 1
YES
NO
Loc 2
YES
NO
Loc 3
YES
NO
4. Completely lighted at night
Loc 1
YES
NO
Loc 2
YES
NO
Loc 3
YES
NO
5. Surveillance camera equipped
Loc 1
YES
NO
Loc 2
YES
NO
Loc 3
YES
NO
6. Is the facility equipped with Intrusion alarm?
Loc 1
YES
NO
Loc 2
YES
NO
Loc 3
YES
NO
7. Lot attended during business hours
Loc 1
YES
NO
Loc 2
YES
NO
Loc 3
YES
NO
8. ARMED Security guards on duty during the day or at night?
Loc 1
YES
NO
Loc 2
YES
NO
Loc 3
YES
NO
9. Fire extinguishers are accessible at each yard
Loc 1
YES
NO
Loc 2
YES
NO
Loc 3
YES
NO
10. Customers’ keys are kept locked in a secure location
Loc 1
YES
NO
Loc 2
YES
NO
Loc 3
YES
NO
Garage Keepers Operations:
11. Do you pick up or deliver customers’ vehicles by driving the vehicle?
Loc 1
YES
NO
Loc 2
YES
NO
Loc 3
YES
NO
12. Do you maintain the proper type and number of fire extinguishers?
Loc 1
YES
NO
Loc 2
YES
NO
Loc 3
YES
NO
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)
YES
NO
5. Municipality, Highway or Turnpike Rotation
YES
NO
6. Voluntary Repossessions
YES
NO
7. Heavy Duty Commercial Towing and Recovery
YES
NO
8. Motor Club towing
YES
NO
9. Towing for banks or finance companies
YES
NO
10.Towing for your own garage/body shop
YES
NO
11. Involuntary Repossessions
YES
NO
Dispatching:
12. Are your tow trucks equipped with Scanners?
YES
NO
13. Do you participate in any “Chase” or first on the Scene towing?
YES
NO
14. Do you require each tow performed by your company to be dispatched by your office dispatcher?
YES
NO
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?
YES
NO
2. Do you have a general liability policy in place covering this operation?
YES
NO
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?
YES
NO
2. Do you have underground gas storage?
YES
NO
3. Do you maintain pollution coverage on all storage tanks above ground and/or below ground?
YES
NO
4. Do you sell Alcoholic Beverages?
YES
NO
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?
YES
NO
3. Do you perform Involuntary Repossessions?
YES
NO
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
YES
NO
Loc 2
YES
NO
Loc 3
YES
NO
2. Do you or have you ever owned or leased a crushing machine?
Loc 1
YES
NO
Loc 2
YES
NO
Loc 3
YES
NO
3. Do you allow third party vendors to perform crushing on your property?
Loc 1
YES
NO
Loc 2
YES
NO
Loc 3
YES
NO
4. Do you allow customers to pull parts from the stored autos?
Loc 1
YES
NO
Loc 2
YES
NO
Loc 3
YES
NO
5. Do you retain a copy of the sales receipt for all parts sold?
Loc 1
YES
NO
Loc 2
YES
NO
Loc 3
YES
NO
6. Does your receipt contain a “Sold as is Warranty”?
Loc 1
YES
NO
Loc 2
YES
NO
Loc 3
YES
NO
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?
YES
NO
Use Trailer Interchange Agreements?
YES
NO
Any drive-away work?
YES
NO
Any transporter plates?
YES
NO
Any vehicle leased/loaned/rented to others?
YES
NO
Any employees/owner operators not listed?
YES
NO
Any owned/leased vehicles not listed?
YES
NO
Haul Boats?
YES
NO
Haul Campers/Mtr Homes?
YES
NO
Haul other Freight?
YES
NO
Auto Dealer?
YES
NO
Auto Repair/Body Shop?
YES
NO
Own or sponsor a car for racing?
YES
NO
Storage Lot/Terminal?
YES
NO
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?
YES
NO
2. Are all drivers performing this work CDL Class “A” licensed drivers?
YES
NO
3. Do you haul, transport or set up Mobile Homes?
YES
NO
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:

14. day a

1. Do you sell auto parts?
NEW
USED
Loc 1
Loc 2
Loc 3
2. Do you sell “third party” remanufactured parts?
Loc 1
YES
NO
Loc 2
YES
NO
Loc 3
YES
NO
3. Does your sales receipt contain a “Sold, as is Warranty”
Loc 1
YES
NO
Loc 2
YES
NO
Loc 3
YES
NO
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
YES
NO
Loc 2
YES
NO
Loc 3
YES
NO
6. Do you perform any type of welding at any location?
Loc 1
YES
NO
Loc 2
YES
NO
Loc 3
YES
NO
7. Do you have any dogs on your premises during or after hours?
Loc 1
YES
NO
Loc 2
YES
NO
Loc 3
YES
NO
8. Do you have gas sales at any location scheduled on this policy?
Loc 1
YES
NO
Loc 2
YES
NO
Loc 3
YES
NO
9. Are there above ground and/or below ground storage tanks at any location?
Loc 1
YES
NO
Loc 2
YES
NO
Loc 3
YES
NO
10. Do you own or lease out limousines, vans or buses?
Loc 1
YES
NO
Loc 2
YES
NO
Loc 3
YES
NO
11. Do you own or operate a car wash at any location?
Loc 1
YES
NO
Loc 2
YES
NO
Loc 3
YES
NO
12. Do you restrict the public from entering your garage work area?
Loc 1
YES
NO
Loc 2
YES
NO
Loc 3
YES
NO
13. Do you provide an area for customers to wait while their vehicle is repaired?
Loc 1
YES
NO
Loc 2
YES
NO
Loc 3
YES
NO
14. Do you operate a convenience store at any location?
Loc 1
YES
NO
Loc 2
YES
NO
Loc 3
YES
NO
15. Is the facility inspected by a governmental agency on an annual basis?
Loc 1
YES
NO
Loc 2
YES
NO
Loc 3
YES
NO
16. Do you retain written records on all repairs performed by your operation?
Loc 1
YES
NO
Loc 2
YES
NO
Loc 3
YES
NO
17. Are repairs performed on private passenger autos?
Loc 1
YES
NO
Loc 2
YES
NO
Loc 3
YES
NO
18. Are repairs performed on commercial autos or heavy equipment?
Loc 1
YES
NO
Loc 2
YES
NO
Loc 3
YES
NO
19. Do you own, sponsor or work on “race cars”?
Loc 1
YES
NO
Loc 2
YES
NO
Loc 3
YES
NO
20. Are ALL of your service and repair mechanics professionally certified?
Loc 1
YES
NO
Loc 2
YES
NO
Loc 3
YES
NO
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
YES
NO
Loc 2
YES
NO
Loc 3
YES
NO
2. Do you have a UL approved Paint Booth?
Loc 1
YES
NO
Loc 2
YES
NO
Loc 3
YES
NO
3. Do you paint cars outside of the booth?
Loc 1
YES
NO
Loc 2
YES
NO
Loc 3
YES
NO
4. Do you perform welding as part of the repair?
Loc 1
YES
NO
Loc 2
YES
NO
Loc 3
YES
NO
5. Do you have a frame-straightening machine?
Loc 1
YES
NO
Loc 2
YES
NO
Loc 3
YES
NO
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
ST
Years Exp
Hire Date
Driving Record
Driver #2 : Name
First
Last
DOB
Drivers License Number
ST
Years Exp
Hire Date
Driving Record
Driver #3 : Name
First
Last
DOB
Drivers License Number
ST
Years Exp
Hire Date
Driving Record
Driver #4 : Name
First
Last
DOB
Drivers License Number
ST
Years Exp
Hire Date
Driving Record
Driver #5 : Name
First
Last
DOB
Drivers License Number
ST
Years Exp
Hire Date
Driving Record
Has every possible driver been identified including part time?
YES
NO
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
The current value if seeking physical damage ?
Vehicle
Cost New
Vehicle Identification number
The current value if seeking physical damage ?
Vehicle
Cost New
Vehicle Identification number
The current value if seeking physical damage ?
Vehicle
Cost New
Vehicle Identification number
The current value if seeking physical damage ?
Vehicle
Cost New
Vehicle Identification number
The current value if seeking physical damage ?
Dealer/Transport Tags
How many?
Tag Number:
Remarks:
Section 22: Insurance History
** (If you are a Missouri applicant SKIP questions 1, 2 and 3 of this section)
1. In the last twelve months, has your insurance been canceled for NON PAYMENT of premium?
YES
NO
2. within the past twenty-four months has an insurance company NON-RENEWED your insurance coverage?
YES
NO
3. What was the date of the Non Renewal?
4. Is the applicant required to carry Workers Compensation insurance based on the laws of the domiciled state?
YES
NO
5. Does the applicant have Workers Compensation insurance coverage at this time?
YES
NO
6. If yes what is the current Experience Modifier:
Losses and Loss History Statement:
Do you have insurance company loss runs from your last five years of operation?
YES
NO
*** If you answered no please review and complete this next section very carefully. ***
Statement of your loss history:It is a requirement that we receive your last five years of insurance company loss runs in order to analyze your operations insurability.If you are unable to obtain the five-year history prior to the inception of coverage and you have less than five vehicles to insure, weare willing to accept your statement of past losses until you can obtain your insurance company loss runs. By signing this applicationyou are agreeing to provide a complete statement of all losses pertaining to the coverage requested on this application and withinforty-five days from coverage inception provide insurance company loss runs
Please list down the Previous Insurance Carriers , Year , Insurance Company Name & # Vehicles Premium Paid
Previous Insurance Carriers - Year - Insurance Company Name - # Vehicles Premium Paid
45346