Sample Bill of Sale Automobile by wvw15691

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									                    MOVING & STORAGE SUPPLEMENTAL QUESTIONNAIRE
    Name:
    Address:
    Web Address:
    Email Address:
    Fed ID:
    Effective Date:

    The following items should accompany this supplemental questionnaire:
                 ACORD Applications *          Sample Bill of Lading           Sample Warehouse Receipt              4 year loss history
                         Drivers List                   Current Financial Statement including Balance Sheet & Income Statement
             *- on the Acord automobile application, please indicate % of Van Line use for each power unit.

1. Date company or predecessor was established:                         Please provide the following information for company
   owners, officers, partners, or managing directors:
                                   Name                                        Title                 Yrs. of             Yrs. of
                                                                                                   Experience         Organization




2. National Van Line affiliation(s), if any:
           a. Special certificates required? (attach)                                                   Yes        No
           b. Are you required to provide primary automobile liability insurance while operating under Van Line or
           other authority?                                                                             Yes        No
              If yes, explain:
           c. List any other authorities you hold:

3. Filings: (Please provide accurate information for proper filing)
            USDOT Name:                                          USDOT#:
                MTMC:                                                      MC/MX #:
             Other filing requirements:

4. Area of Operation:      While operating under your own primary automobile insurance:
      What cities (metropolitan areas) do you service?
      Normal radius of operation:              0 – 50 miles     %
                                             51 – 100 miles     %
                                            100 – 250 miles     %
                                            Over 250 miles      % (Attach last four fuel tax schedule reports)
5. Do you:           Act as a freight forwarder?                                                                                Yes        No
                     Arrange for shipments by air or rail?                                                                      Yes        No
                     Arrange for shipments overseas?                                                                            Yes        No
       If yes to any of the above, explain:

6. Are you a subsidiary of another entity or do you have any subsidiaries?                                                      Yes        No
      If yes, explain:

7. Do you conduct any other business other than moving and storage (i.e., sale or manufacture of boxes, self-storage,
   furniture or fixture installation, rigging, equipment rental, and auto repair)?                    Yes         No
      If yes, explain:

8. Do you use contract drivers or owner/operators?                                                                              Yes        No
     If yes, are contract driver or owner/operator vehicles scheduled on this policy?                                           Yes        No
     Do they haul exclusively for you?                                                                                          Yes        No
9. Do others own any scheduled vehicles?                                                                 Yes       No
     If yes, explain:

10. What is the average annual cost of renting or leasing vehicles not shown on the auto policy? $

11. What percentage of your off-premises packing and crating is done by your employees (not independent or sub-
    contractors)?      %

12. Do you issue a bill of lading or other contract on all moves?                                        Yes       No
      If no, explain:

13. What is the estimated annual employee turnover ratio for key positions including managers, supervisors, drivers,
    etc.)?       %

14. Hiring practices:   a. Do you lease employees form an employee leasing firm?                         Yes       No
                               (If yes, attach a copy of the leasing agreement.)
                        b. Do union hiring practices preclude employee selection based upon skill?       Yes       No
                        c. Is there a formal applicant screening process?                                Yes       No
                        d. Are there written job descriptions with minimum qualifications?               Yes       No
                        e. Are experience and qualifications verified for each new hire?                 Yes       No
                         f. Are demonstrations of “critical skills” required prior to employment?        Yes       No

15. How are drivers compensated?                  Hourly            Per Trip      Other

16. Do you obtain and review MVR’s on new drivers prior to hiring?                                       Yes       No
17. What are your criteria for acceptable driving records?    # of violations        # of accidents
                                                              # of violations/accidents combined
18. Do you review MVR’s for all drivers at least annually?                                               Yes       No
19. Do you have a formal written safety program?                                                         Yes       No
20. Do employees participate in the analysis of exposures and review of losses?                          Yes       No
21. Does you have established procedures in place to minimize losses and exposures to loss?              Yes       No
22. Is there a written vehicle maintenance program?                                                      Yes       No
    Does it include:    a. Regular, preventive maintenance?                                              Yes       No
                        b. Certified mechanics?                                                          Yes       No
                        c. Safety & Pre-trip inspections?                                                Yes       No




    Please sign:


    Date:




                                                              2
                        LIABILITY AS A WAREHOUSE OPERATOR
23. Types of Goods Stored:
           % Used HHG        % New HHG                    % Military HHG            % Office Furnishings
           % Electronics     % Fine Arts                  % Antiques                % Business Records
           %    General Commodities - Describe:

   Provide the following information for each location where you store goods.

                                        Location 1                    Location 2                    Location 3
   Address: Street
    City, State, ZIP
   Year Building was Built
   Sprinklered?                         Yes          No              Yes          No               Yes          No
   Property Skidded?                    Yes          No              Yes          No               Yes          No
   Alarm:                               Central Station              Central Station               Central Station
                                              Local                        Local                         Local
   Exterior, yard lighted?              Yes          No              Yes          No               Yes          No
   Premises fenced?                     Yes          No              Yes          No               Yes          No
   Security camera?                     Yes          No              Yes          No               Yes          No
   Area:
   % containerized storage
   How high are containers
   stacked (1, 2, or 3 high)?
   % rack storage
        % Other Storage                          %                              %                           %
            (describe)
   % rented to others
   Average number of
   containers under released
                                          #                            #                             #
   value of $1.25 or less
   Total estimated value of
   containers at released
   value
   Average number of
   containers under declared
                                          #                            #                             #
   value of more than $1.25
   Average declared value                 $                            $                             $
   Maximum declared value                 $                            $                             $
   Total estimated value of
   containers at declared
                                          $                            $                             $
   value
   Total estimated value of
   non-containerized storage              $                            $                             $
   Storage/Handling
   Revenue                                $                            $                             $
   Warehouse Payroll                      $                            $                             $
   Warehouse Limit of
   Liability                              $                            $                             $


   Deductible:         $1,000          $2,500          $5,000           Other $




                                                            3
                                LIABILITY AS A CARRIER FOR HIRE

24. What is your expected gross transportation revenue for the next 12 months? $
                          The following annual Revenue Summary needs to be completed

    % of Cargo Revenue that is under released value of $1.25 or less           %

25. Types of Goods Carried:
         % Used HHG          % New HHG                        % Military HHG                     % Office Furnishings
         % Electronics       % Fine Arts                      % Antiques                         % Business Records
         % General Commodities - Describe:
26. Do you do on-site furniture installation or assembly?                                                    Yes        No
           If yes, payroll? $          Explain:
27. Do you do hoisting or rigging?                                                                           Yes        No
           If yes, explain:
28. Have you hauled any shipments valued over $200,000 in the past 12 months?                                Yes        No
           If yes, explain:
29. Do you have interchange agreements with other moving companies (excl. van line affiliation)?             Yes        No
           If yes, explain:


                                                    Limits of Insurance
       $25,000 any one unit              $ 50,000 any one unit             $ 75,000 any one unit
       $50,000 any one loss              $100,000 any one loss             $150,000 any one loss

       $100,000 any one unit             Other: $       any one unit
       $200,000 any one loss                    $       any one loss

    Deductible:         $1,000           $2,500             $5,000         Other $



                                               OPTIONAL LIMITS
    Uncollectible Charges:                                             $       any one customer ($2,000 included)

                                                                       $       any one occurrence ($20,000 included)


    Inventory Cost:                                                    $            ($5,000 included)




                                            OTHER COVERAGES

    Miscellaneous Moving Equipment & Packing Material:                 $
    Forklifts & Other Self-propelled vehicles including spare parts    $

    Portable Electronic Equipment                                      $

    Deductible:         $ 500            $1,000             $2,500         $5,000              Other $

                                                               4
          ANNUAL TRANSPORTATION REVENUE SUMMARY
                                    FOR THE YEAR




PRIMARY AUTO LIABILITY TRANSPORTATION REVENUE BREAKDOWN

                        Total Transportation       % Under Your own   % Other or Van Line
                           Revenues ($)              Authority (%)       Authority (%)

LOCAL INCL HAULS
UNDER 250 MILES:            $                                %                    %

HAULS OVER 250 MILES:
                            $                                %                    %
INTERNAITONAL:
                            $                                %                    %

CARGO REVENUE BREAKDOWN

                        Total Transportation       % Under Your own   % Other or Van Line
                           Revenues ($)              Authority (%)       Authority (%)

LOCAL INCL HAULS
UNDER 250 MILES:            $                                %                    %

HAULS OVER 250 MILES:
                            $                                %                    %
INTERNAITONAL:
                            $                                %                    %




                                               5
      $                                %                     %
INTE RNAITONA L:
                            $                                %                     %




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