Your Federal Quarterly Tax Payments are due April 15th Get Help Now >>

AutomobileServiceandRepairSuppApp by niusheng11


									                                                       Automobile Service and Repair
                                                             (This program excludes Dealers)
                                                          Supplemental Questionnaire

Applicant:                                                                      Date:

Agent:                                                                          Quote need by date:

                                                                    Service Work

1. Identify the amount of work performed as a percentage of total annual revenue:

                                                   Main Automobile Service and Repair Operations
   a. Auto air conditioning repair/service                           %      b. Auto body repair                                      %
   c. Auto painting                                                  %      d. Brake, front end & wheel alignment                    %
   e. Carburetor repair                                              %      f. Electrical repair                                     %
   g. Exhaust system repair                                          %      h. Engine service or repair                              %
   i. Oil change and lubrication                                     %      j. Radiator repair                                       %
   k. Transmission Repair                                            %
                                                                  Ancillary Operations
   a. Alarm sales and installation                                   %      b. Audio/Visual equipment installation                   %
   c. Auto detailing                                                 %      d. Auto glass tinting/repair/installation                %
   e. Auto parts accessories sales and                               %      f. Camping trailer shell sales and installation          %
   g. Auto upholstery repair                                         %      h. Gasoline sales                                        %
   i. Rust proofing                                                  %      j. Tire sales, service and repair                        %
   k. Vehicle safety & smog inspections                              %
                                                              Miscellaneous Operations
   a. Antique auto restoration                                       %      b. Auto sales                                            %
   c. Auto storage                                                   %      d. Car rental (loaner cars)                              %
   e. Car washes                                                     %      f. Customers shuttle service                             %
   g. For-hire towing                                                %      h. LPG sales                                             %
   i. LRO operations                                                 %      j. Mobile repairs                                        %
   k. Retail sales (snacks, deli)                                    %      l. Salvage and dismantling                               %
   m. Truck bed liner installation                                   %      n. Other:                                                %
2. Number of employees:         Full time:                         Part time:

3. Is there at least one ASE certified technician employed who supervises all work in the shop?           Yes    No

4. Does the building contain aluminum wiring?          Yes     No

5. Are there guard dogs on premises?         Yes      No

   If yes, are they provided by a third party?      Yes      No

                                                                                                                              Page 1 of 4
   If yes, does the third party provide the insured with a hold harmless, indemnification and is the insured named as an additional insured in a
    written contract?        Yes      No

6. Do employees drive all customers’ vehicles in and out of the garage area?                  Yes         No

7. Are customers allowed in the garage area?           Yes           No

8. Do customers sign an estimate for all work to be performed on their vehicle?                    Yes         No

9. Are loaner cars provided to customers?           Yes         No

   If yes, does the insured retain a copy of the driver’s license and insurance card?                   Yes      No

   And are drivers limited to those age 25 and older?            Yes        No

10. Are customers’ keys kept on a key board?           Yes           No

   If yes, is the key board locked up at night?        Yes           No

11. Are customers’ keys kept in lock boxes on the car?               Yes     No

   If yes, who has access to the lock box at night?

12. Sublet Operations:
    Does the insured have a contract with hold harmless, indemnification and additional insured status?                    Yes     No        N/A

    Does the insured also have a current certificate of insurance that has at least $1,000,000 GL or Garage limits per occurrence?                  Yes        No

13. Does the insured rebuild, modify or remanufacture parts?                Yes    No

   If yes, please explain:

14. Does the insured have Vendor’s Coverage from the suppliers of all new, rebuilt or remanufactured parts or accessories?                    Yes         No

   If no, please explain:


1. Are self-closing, fusible link metal containers used for oily rag storage?           Yes         No

2. Is the solvent tank product non-flammable?             Yes         No

   If no, is the solvent kept in a self-closing, fusible link metal container?          Yes         No

3. Are all flammable liquids stored in a metal fire cabinet or fusible link metal container?                   Yes    No

4. Are bulk quantities of flammable liquids stored away from the buildings?               Yes            No

5. Do all gas/LPG pumps/tanks have barriers for impact protection?                Yes         No

6. Are all gas tanks equipped with a shut off switch with good signage?             Yes            No

                                                           Garagekeeper’s Legal Liability

1. Does the insured confirm with customers that they have removed anything of value from their vehicles?                     Yes        No

                                                                                                                                                   Page 2 of 4
   Are there signs in the shop to this effect?       Yes      No

2. Is the yard perimeter posted with “No Trespassing” signs?             Yes        No

3. Is the yard fenced?       Yes       No           Gated?         Yes         No                        Well lighted?             Yes          No

                                                                   Pollution Liability

1. Do gas, diesel or other hazardous material underground tanks have location-specific pollution coverage?               Yes             No          N/A

2. Are all above ground tanks (in excess of 50 gal.) within a containment berm and protected with posts?               Yes          No          N/A

   If no, please explain:

3. Are connection hoses from pollutant type product containers regularly checked for wear and tear and regularly replaced?                           Yes   No

4. Are pollutants handled and disposed of according to local, state and federal environmental regulations?               Yes         No

5. Does the insured dispose of all hazardous waste through a licensed contractor who specialized in such operations?                      Yes         No

6. Do all third party contractors disposing of the insured’s pollutants provide the insured with additional insured coverage (including pollution
   coverage), hold harmless and an indemnification?           Yes     No

   If yes, does the insured maintain Certificates of Insurance from these contractors?           Yes         No

7. Has the insured previously had a pollution claim, (covered by insurance or not)?            Yes      No

   If yes, please explain:

                                                                    Collision Repair

                                   Auto Body Repair (Skip this section if insured does not perform auto body repair)

1. Does the insured have the ability to remove and reinstall frame, suspension, engine and drive train components?                       Yes         No

   If no, please explain:

2. Does the insured subscribe to a provider for structural specifications with periodic updates covering the specific vehicle structures, wheel
   alignment, etc. for make, model and year of vehicles?         Yes      No

3. Is old paint removal done in a booth designed with dust collection?              Yes   No

4. Do you have employees that are qualified to diagnose the condition of airbags and other occupant restraint systems and capable of
   completing OE (Original Equipment)-specified repairs using in house equipment with certified technicians?       Yes     No     N/A

                                            Welding (Skip this section if insured does not perform welding)

1. Are only certified welders authorized to use equipment?            Yes       No

2. Do the certified welders adhere to safety techniques including but not limited to:

   a. Fuel gas tanks are properly stored with cylinders secured in a canister stand or cart?           Yes        No     N/A

   b. Have signs posted reading; NO SMOKING, NO MATCHES OR OTHER FLAMMABLES in the welding area?                             Yes          No         N/A

                                                                                                                                                      Page 3 of 4
   c. Have suitable fire extinguisher in the immediate area?                Yes          No         N/A

   d. If the object being welded is not in a separate fire safe location, shields are to be used to confine heat, sparks and slag and a fire watcher is
       assigned for 30 minutes after the hot work is done?          Yes      No       N/A

   e. Wear appropriate eye protection helmets, gloves, long pants and shirt sleeves, and an apron or coveralls?            Yes      No      N/A

   f. If No or N/A to any of the above, please explain:

                                          Paint Booths (Skip this section if insured does not paint vehicles)

1. Does the insured have a UL, ETL or SCA approved paint booth?                    Yes         No

   If no, please explain:

2. Does the insured have a certified refinish technician on staff?                Yes          No

3. Does the insured provide non-certified employees the opportunity to participate in technical training and certification programs?
      Yes      No

4. Is proper safety equipment provided for employees?                 Yes         No

5. Does the insured properly dispose of spray booth filters and hazardous waste?                          Yes        No

                                            Towing (Skip this section if insured does not perform towing)

1. Are all tow/tilt truck drivers a minimum of 25 years old?            Yes             No

2. Do all drivers have experience or training with tow trucks or tilt bed trucks?                    Yes        No

3. Are all tow/tilt trucks appropriately equipped with flashing yellow/red/blue lights as required by the local jurisdiction?       Yes      No

4. Is a tow receipt signed by the customer?           Yes        No

5. Does the receipt contain a disclaimer that the towing company is not responsible for the contents left in the vehicle?          Yes      No

6. Are people allowed to ride in a vehicle in tow or on a tilt bed?               Yes          No

                                                                      Other Exposures

1. Does the insured have dealer plates?         Yes         No

   If yes, explain when these are used:

2. Are all car washes posted with signs: (e.g., roll up windows, put down antennas, etc.) and a disclaimer regarding possible damage to after-
   market products added to the exterior of the vehicle?          Yes    No     N/A

3. Does the insured own or sponsor a car or other vehicle for racing?                    Yes        No

                              E-mail submission to or fax to 206.826.2828

                                                                                                                                          Page 4 of 4

To top