Fillable Application - Motorcycle Dealerships36-9616

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Application - Motorcycle Dealerships36-9616

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MOTORCYCLE DEALERSHIP APPLICATION
SUBMISSION REQUIREMENTS
• Completed ACORD Application
• PIC Supplemental Motorcycle Dealership Application
• Photographs of all locations
• Hard copy company loss runs for 3 – 5 prior years coverage.
Loss letters are not acceptable
• Brochure or website address
• Financial Statement
• Employee list, title, driver’s license and date of birth
• Copy of test-drive procedures
• Dealer Physical Damage Inventory
GENERAL INFORMATION
Applicant Name:
Mailing Address:
Website:
Telephone Number:
Number of years in business under current ownership:
If less than three years, describe experience of management.
SECTION I – FRANCHISE(S)
Aprila
Honda
Kawasaki
Bombardier/Can Am
Ducati of North America, Inc.
Buell
Yamaha
Big Dog
Seadoo/Bombardier
Harley-Davidson
BMW
Triumph
Other:
SECTION II – OPERATIONS PERCENTAGE OF TOTAL RECEIPTS
Apparel/Accessories:
Motorcycles:
ATVs:
Scooters:
Lawn and Garden:
Boats:
Personal Watercraft:
Snowmobiles:
Describe any operations not listed above:
SECTION III – AUTOMOBILE LIABILITY
1.
Demo Policy:
Does the Applicant provide demos?
Yes
No
Number of auto demos:
Who gets a demo?
Number of motorcycle demos:
Who gets a demo?
Furnished Autos:
Name
Driver’s License
Number
Date of Birth
Relationship to
Dealer
Household
member
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Motorcycle Dealership Application
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© 2020 Philadelphia Consolidated Holding Corp.
03/2020
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2.
Number of dealer plates:
Test Drive Procedures:
3.
Motorcycles/ATVs:
Test drives?
Yes
No
Route with right turns?
Yes
No
Designated route?
Yes
No
Check for valid motorcycle license?
Yes
No
100% accompanied by salesperson?
Yes
No
4.
Watercraft:
Test drives?
Yes
No
If yes, what bodies of water?
If yes, how far from the dealership?
What is the minimum age required for customers to be passengers on demonstration rides with
employees?
Does the Applicant require customers sign a hold harmless agreement?
Yes
No
Are customers allowed to drive the boat?
Yes
No
Are customers required to wear life vests?
Yes
No
Is the area of demonstration defined?
Yes
No
Is a recovery boat present during demonstration rides?
Yes
No
Is adequate lifesaving equipment available during demonstration rides?
Yes
No
5.
Customer Loaner/Rental Policy:
Does the Applicant have a loaner program?
Yes
No
If yes, how many?
What are the minimum age requirements?
Does the Applicant obtain a copy of the driver’s license?
Yes
No
Does the Applicant verify insurance on the driver?
Yes
No
Describe any products available for customer rental:
ATV
Apparel
Helmets
Motorcycles
Scooters
Snowmobile
Other:
Who insures the rentals?
6.
Employee Automobile Information:
Does the Applicant have a formal driving policy in place with MVR standards?
Yes
No
If yes:
a.
Is driving policy communicated in writing to all employees?
Yes
No
b.
Is a signed acknowledgement form kept on file?
Yes
No
If yes, please provide a copy of signed acknowledgement.
c.
Do driving standards include the following:
i.
No major violations including DUI, racing, hit and run, speeding in excess of 20 mph
over posted speed limit, manslaughter?
Yes
No
ii.
No more than 2 moving violations within past 3 years?
Yes
No
iii.
No more than 1 at fault accident within past 3 years?
Yes
No
How often does the Applicant check MVR reports?
Does the Applicant allow any newly hired drivers to operate vehicles without going through a
company-specific documented driver training?
Yes
No
Describe any ongoing training provided to drivers:
Does the Applicant have GPS tracking capability?
Yes
No
Does the Applicant allow employees to drive personal vehicles for company purposes?
Yes
No
If yes:
a. Are the driving policy and standards for these drivers the same as in the first three
questions in this section? Yes No
b. Does the Applicant require these employees to have adequate personal insurance limits? Yes No
Motorcycle Dealership Application
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© 2020 Philadelphia Consolidated Holding Corp.
03/2020
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SECTION IV – PHYSICAL DAMAGE
1.
Inventory by Location:
1. $
2. $
3. $
4. $
5. $
Is inventory stored inside?
Yes
No
If yes, maximum number per location:
1.
2.
3.
4.
5.
2.
Does the Applicant have a formal plan addressing:
Hurricane
N/A
Yes
No
Flood:
N/A
Yes
No
(If yes, please attach a copy of the plan.)
3.
Protection:
Location 1
Location 2
Location 3
Location 4
Location 5
Areas fenced/gated?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Video surveillance?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Security lighting?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Private security?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Chains?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
4.
Hauling (Transportation):
Does the Applicant transport motorcycles?
Yes
No
If yes, explain:
5.
What type of vehicle is used to transport motorcycles?
6.
Does the Applicant employ sub-contractors to transport motorcycles?
Yes
No
If yes, does the Applicant obtain proof of insurance from sub-contractor?
Yes
No
7.
Customer Storage:
Does the Applicant offer seasonal customer storage?
Yes
No
If yes, values:
Max number of bikes dealer is capable of storing:
Are fuel tanks drained while stored?
Yes
No
8.
Employees:
Hiring Procedures
Applications?
Yes
No
Drug screening?
Yes
No
Reference/Prior employer checks?
Yes
No
Applicant provides MVR with application?
Yes
No
Other:
SECTION V - LIABILITY
1.
Premises
Are customers allowed in service area?
Yes
No
Does the Applicant have curbs, steps and ramps clearly painted/marked?
Yes
No
Are customers allowed to load/unload bikes, ATVs, snowmobiles?
Yes
No
2.
Other Operations/Other Legal Entities:
Is the Applicant involved in anything other than the sale or service of vehicles?
Yes
No
If yes, describe:
Any ownership of other properties?
Yes
No
If yes, describe:
Motorcycle Dealership Application
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03/2020
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3.
Food/Drink Service:
Does the Applicant have a food or drink operation?
Yes
No
If yes, describe:
Are alcoholic beverages served or sold?
Yes
No
If food service is provided, complete restaurant survey.
4.
Hitch Sales/Installation:
Is the Applicant involved in anything other than the sale or service of vehicles?
Yes
No
If yes, how many per year?
5.
Special Manufacturing or Customization:
Is the Applicant involved in any manufacturing or customization work?
Yes
No
If yes, describe:
Does the Applicant manufacture and/or sell trikes, sidecars, and/or 3-wheeled conversions?
Yes
No
6.
Racing or Rallies: N/A
Does the Applicant participate in or have affiliation with organized racing events or rallies?
Yes
No
If yes, describe:
SECTION VI – SPECIAL HAZARDS
1.
Welding / Cutting
N/A
Location 1
Location 2
Location 3
Location 4
Location 5
Always done in
designated area?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Welding done
within last hour of
operation?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Are oxygen and
acetylene spare
tanks separated?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Spare cylinders
secure to wall or
post?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Welding blankets
used?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Gasoline Tanks
N/A
Gasoline tank
draining performed
with Gas Caddy?
If no, risk is
ineligible.
Yes No Yes No Yes No Yes No Yes No
Motorcycle Dealership Application
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03/2020
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FRAUD STATEMENT AND SIGNATURE SECTIONS
The Undersigned states that he/she is an authorized representative of the Applicant and declares to the best of his/her knowledge and belief
and after reasonable inquiry, that the statements set forth in this Application (and any attachments submitted with this Application) are true
and complete and may be relied upon by Company * in quoting and issuing the policy. If any of the information in this Application changes
prior to the effective date of the policy, the Applicant will notify the Company of such changes and the Company may modify or withdraw the
quote or binder.
The signing of this Application does not bind the Company to offer, or the Applicant to purchase the policy.
*Company refers collectively to Philadelphia Indemnity Insurance Company and Tokio Marine Specialty Insurance Company
VIRGINIA APPLICANT: READ YOUR POLICY. THE POLICY OF INSURANCE FOR WHICH THIS APPLICATION IS BEING MADE, IF ISSUED,
MAY BE CANCELLED WITHOUT CAUSE AT THE OPTION OF THE INSURER AT ANY TIME IN THE FIRST 60 DAYS DURING WHICH IT IS IN
EFFECT AND AT ANY TIME THEREAFTER FOR REASONS STATED IN THE POLICY.
FRAUD NOTICE STATEMENTS
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR
INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION
CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THAT PERSON TO
CRIMINAL AND CIVIL PENALTIES (IN OREGON, THE AFOREMENTIONED ACTIONS MAY CONSTITUTE A FRAUDULENT INSURANCE ACT WHICH MAY
BE A CRIME AND MAY SUBJECT THE PERSON TO PENALTIES). (IN NEW YORK, THE CIVIL PENALTY IS NOT TO EXCEED FIVE THOUSAND DOLLARS
($5,000) AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION). (NOT APPLICABLE IN AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN,
NM, OK, PA, RI, TN, VA, WA AND WV).
APPLICABLE IN AL, AR, AZ, DC, LA, MD, NM, RI AND WV: ANY PERSON WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS A FALSE OR
FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS FALSE INFORMATION IN AN
APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES OR CONFINEMENT IN PRISON.
APPLICABLE IN COLORADO: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN
INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE
IMPRISONMENT, FINES, DENIAL OF INSURANCE AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO
KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A POLICYHOLDER OR CLAIMANT FOR THE PURPOSE
OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM
INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY
AGENCIES.
APPLICABLE IN FLORIDA AND OKLAHOMA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER
FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A
FELONY (IN FL, A PERSON IS GUILTY OF A FELONY OF THE THIRD DEGREE).
APPLICABLE IN KANSAS: AN ACT COMMITTED BY ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE
PRESENTED OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, PURPORTED INSURER, BROKER
OR ANY AGENT THEREOF, ANY WRITTEN, ELECTRONIC, ELECTRONIC IMPULSE, FACSIMILE, MAGNETIC, ORAL, OR TELEPHONIC COMMUNICATION
OR STATEMENT AS PART OF, OR IN SUPPORT OF, AN APPLICATION FOR THE ISSUANCE OF, OR THE RATING OF AN INSURANCE POLICY FOR
PERSONAL OR COMMERCIAL INSURANCE, OR A CLAIM FOR PAYMENT OR OTHER BENEFIT PURSUANT TO AN INSURANCE POLICY FOR
COMMERCIAL OR PERSONAL INSURANCE WHICH SUCH PERSON KNOWS TO CONTAIN MATERIALLY FALSE INFORMATION CONCERNING ANY FACT
MATERIAL THERETO; OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO.
APPLICABLE IN KENTUCKY: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSONS
FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF
MISLEADING, INFORMATION CONCERNING ANY MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.
APPLICABLE IN MAINE, TENNESSEE, VIRGINIA AND WASHINGTON: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING
INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT,
FINES OR A DENIAL OF INSURANCE BENEFITS.
APPLICABLE IN PENNSYLVANIA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON
FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE
PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A
CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.
APPLICABLE IN VERMONT: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE STATEMENT IN AN APPLICATION FOR INSURANCE MAY BE GUILTY
OF A CRIMINAL OFFENSE AND SUBJECT TO PENALTIES UNDER STATE LAW.
APPLICABLE IN NEW YORK: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON
FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE
PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A
CRIME AND SHALL BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATE VALUE OF THE CLAIM FOR EACH
SUCH VIOLATION.
NA
ME (PLEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR EXECUTIVE DIRECTOR)
_____
________________________________________________________
SIGNATURE DATE
SE
CTION TO BE COMPLETED BY THE PRODUCER/BROKER/AGENT
PRODUCER AGENCY
(If this is a Florida Risk, Producer means Florida Licensed Agent)
PRODUCER LICENSE NUMBER
(If this a Florida Risk, Producer means Florida Licensed Agent)
ADDRESS (STREET, CITY, STATE, ZIP)
Motorcycle Dealership Application
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03/2020
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