Docstoc

Business Insurance naire CAR WASH

Document Sample
Business Insurance naire CAR WASH Powered By Docstoc
					MOODY INSURANCE WORLDWIDE
Business Insurance Questionnaire – CAR WASH FACILITIES



GENERAL INFORMATION
How did you hear about Moody?


Business Name

(incl Corp and T/A names):


Contact Person:                                                                          Title:


Mailing Address:


Location Address:


Phone:                                          Fax:                                     Email:


                                                                                                                     Date business
Entity Type (Corp, Sole Prop, LLC, etc):                                 Federal ID #:
                                                                                                                     started:


If New Venture, prior experience:                                                        Website:


Please list all states in which you do business:


Business Description (including typical services
performed, clients served, products, etc.):


Do you operate any other type of business or own any                               If Yes, please
                                                            Yes     No
other building than listed on this form?                                           provide details:


                       PLEASE ATTACH COPIES OF YOUR CURRENT POLICY DECLARATIONS PAGES FOR MOST ACCURATE QUOTE 


LOCATION / BUILDING INFORMATION

Type of building you occupy
                                                                                                                   Sq Ftg You Occupy:
(office, retail strip mall, industrial, etc.)


                          Approx Year                  Construction (Frame, Masonry,                                     % of Bldg
Stories:
                          Built:                       Noncombustible, Fire Resistive, etc):                             Sprinklered:


If bldg over 30 yrs old, Year(s) Updated for                                             Alarm? Burglar or Fire?


                                                                                                                                Page 1 of 6
Wiring, Heating, Plumbing, Roof:                                                             Local or Central Station?

PROPERTY

                                                  ►Contents Replacement                                   Improvements &
Building:
                                                  Value:                                                  Betterments:


Business Income &                                                                                         Computer Software
                                                  Computer Hardware:
Extra Expense:                                                                                            (data & media):


Valuable Papers:                                  Accounts Receivable:                                    Exterior Sign?


Building Glass                                    Other Property Used or Stored Off
(measurements):                                   Premises (describe & value):


Total Misc Mobile Tools & Equipment                                   Scheduled Mobile Equipment
                                                                                                                                ATTACH SCHEDULE
(under $1000 per item):                                               (for individual items exceeding $1,000):


Do you rent or loan equipment to others? If
                                                   Yes      No
Yes, please provide details:


►Contents may include, but is not limited to: Leasehold Improvements, Leased Property, Inventory, Furniture/Fixtures, Equipment, Printed Materials,
Consumables, and Property of Others in Your Care.


CRIME


Employee Dishonesty                                        401(k) Plan?
Limit:
                                                           If Yes, Plan Name:


Forgery/Alteration                                         Theft of Money                                      Computer
Limit:                                                     (Inside/Outside):                                   Fraud Limit:

GENERAL LIABILITY
                                                                                General Aggregate Limit
Each Occurrence Limit:
                                                                                (if other than 2x Occurrence):


Fire Legal Liability Limit                                                      Medical Payments Limit

(if other than $50,000):                                                        (if other than $5,000):


                                                                                                                                        Yes         No
Estimated Annual                                                                Do you use Subcontractors?



                                                                                                                                      Page 2 of 6
Gross Receipts:                                                        If so, explain below work subcontracted


What percentage of your total                     Do you require Subs to have insurance and                              If No, explain
                                                                                                     Yes     No
work is subcontracted?                            do you obtain Certificates of Insurance?                               below


Comments:

WORKERS COMPENSATION | OWNERS | List below all owners/officers of the business, whether active or inactive

                                                                           Duties                                            Include or
           Owner/Officer Name                    Title                                              Annual Payroll
                                                                                                                              Exclude?
                                                                   (or indicate if inactive)




WORKERS COMPENSATION | Please review your current policy for all classes & codes

            Employee Class or                  Code             Estimated Annual Payroll         # FT              # PT
                                                                                                                                 State
          Description of Duties              (if known)        (don’t include owners here)     Employees         Employees




Do you lease employees to or from other
                                               Yes        No
employers? If Yes, please provide details:


Do you use volunteers?                         Yes        No


                                                                                                                        Page 3 of 6
 If Yes, for what type of work?


 Employers Liability Limits

 (if other than $100,000 / $500,000 / $100,000):

AUTOMOBILE

Auto Liability                                                         Uninsured / Underinsured
                                                                       Motorist Limit(s):
(Combined Single or Split Limits):


Medical Payments:                                                      Personal Injury Protection:


Comp Deductible:                                                       Collision Deductible:


Towing & Labor
                                                                       Rental Reimbursement:
(for private passenger vehicles):


If any owners / key employers have their personal vehicles on

policy, please give their names and names of their spouses:


Do you rent vehicles for business use?                 Yes        No             If Yes, # of days per year


Do employees use personal vehicles for business?       Yes        No             If Yes, for what purposes?


VEHICLE SCHEDULE | Please complete the below or attach a separate schedule of your own

                                                                                 Original                               ** Titled/Leased in
 Year       Make / Model                 Vehicle ID (Serial Number)                              Garaging City, State
                                                                                Cost New                                 business name?



                                                                                                                        Yes       No




                                                                                                                        Yes       No




                                                                                                                        Yes       No




                                                                                                                        Yes       No




                                                                                                                              Page 4 of 6
                                                                                                                            Yes       No




                                                                                                                            Yes       No



 ** For vehicles not titled/leased in the business name, please indicate the name of the titled owner or lessee for each vehicle:




DRIVER SCHEDULE | Please complete the below or attach a separate schedule of your own

          Driver Name (as shown on license)                   Drivers License Number               State                Date of Birth




OTHER COVERAGE TO CONSIDER | Would you like more information or a quotation on…..?


Umbrella Liability Policy:            Yes        No                   Employee Benefits Liability:          Yes        No


Employment Practices Liability:       Yes        No                   Directors & Officers Liability:       Yes        No


Errors & Omissions
                                      Yes        No                   Fiduciary Liability:                  Yes        No
Professional Liability:


International:                        Yes        No                   Other Coverage Not Shown:             Yes        No


INSURANCE CARRIER HISTORY
Have you had insurance coverage declined, cancelled or non-renewed during the last 3 yrs?                  Yes    No

If Yes, please provide details:

        Coverage / Policy                       Company                       Expiration Date                How Long with this Company



                                                                                                                                  Page 5 of 6
Property & General Liability


Automobile


Workers Compensation


Umbrella


Other:


CLAIMS / LOSS INFORMATION

IF YOU ARE NOT A NEW VENTURE AND HAVE HAD PRIOR INSURANCE COVERAGE –



PLEASE SEND US YOUR CLAIMS HISTORY FOR THE LAST 3 POLICY YEARS. PLEASE CONTACT YOUR CURRENT AGENT, AND PREVIOUS AGENT(S)
IF NECESSARY, AND REQUEST YOUR “HARD COPY LOSS RUNS FOR ALL POLICIES.”

CAR WASH OPERATIONS SUPPLEMENT

Type of car wash operation:                                       Auto           Manual


Attendant on premises at all times?                               Yes       No


Are floors properly finished to prevent slips/falls?              Yes       No


For self-service washers, how often are consoles emptied of cash and deposits made?


COMMENTS AND OTHER INFORMATION




    20251 Century Blvd, Suite 425, Germantown, MD 20874   301-417-0001   fax 301-417-0040   800-966-0001   www.moodyinsurance.com




                                                                                                                      Page 6 of 6

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:10
posted:7/1/2012
language:
pages:6