Fillable Bicycle Manufacturer/Distributor Product Questionnaire (Risk Placement Services, Inc.)

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Bicycle Manufacturer/Distributor Product Questionnaire (Risk Placement Services, Inc.)

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Bicycle Manufacturer/Distributor Product Questionnaire
Name of Business_______________________________________ Year Business Started________
Address _________________________________________ Total Sales:
_________________________________________ This Year $____________
1st Prior Yr. $____________
2nd Prior Yr. $____________
3rd Prior Yr. $____________
Contact Person:_____________________________
Phone: _____________________
Operations:
Bicycle Manufacturer Bicycle Component Manufacturing
Bicycle Assembly (components manufactured by others) Accessory Manufacturer (gloves,
Distributor clothing, packs, etc.)
Describe Operations:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Describe Operations not related to the Bicycle Industry:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Do you sponsor any professional racing teams? ________ If Yes, Describe:_______________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Do you sponsor any professional bicycle racing events?______If Yes, Describe:___________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Please Provide:
1) Copies of all current advertising material. attached to follow
2) Copies of all current products brochures attached to follow
3) Full details on any products claims attached to follow
(all claims open or closed)
Describe product quality control program:
_______________________________________________________________________________________
_______________________________________________________________________________________
How are your new product lines tested to comply with Consumer Product Safety Commission (CPSC)
bicycle regulation? ______________________________________________________________________
_______________________________________________________________________________________
Do your records enable you to track product runs or sales to the dealer for recall? If Yes, Describe:
_______________________________________________________________________________________
_______________________________________________________________________________________
Manufacturer app rev 6 2015
In order to pr
ovide a quote, Acord 125, 126 and 140 must be completed along with the supplemental.
Please check below the kinds of operations conducted in your manufacturing facility:
Your Operation or Contracted to Others
 Assembly 
 Carbon Fiber Products Manufacturing 
 Casting of Metal Parts 
 Electroplating or Anodizing 
 Fabric Sewing 
 Heat Curing Oven 
 Machining Metal 
 Other Plastic Products Manufacturing 
 Plastic Products Injection Molding 
 Polishing and Buffing 
 Spray Painting 
 Welding - Steel/Aluminum 
 Welding - Titanium 
Other (List) _____________________ 
 Other (List) _____________________ 
Please describe your manufacturing process. ________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Do your subcontractors carry insurance coverages or limits less than yours?_____________
LIST OF ALL CURRENT PRODUCTS- Manufactured or Sold
Product Name Description Check Box Volume
______________________ ___________________________
Manufactured $________Sales
_________________________ Imported (by You) $________Units
_________________________ Wholesaled
____________________ _________________________ Manufactured $________Sales
_________________________ Imported (by You) $________Units
_________________________ Wholesaled
____________________ _________________________ Manufactured $________Sales
_________________________ Imported (by You) $________Units
_________________________ Wholesaled
List and describe additional products to be released in the next two years.
________________________________________________________________________________
________________________________________________________________________________
List and describe any discontinued products that are not related to the bicycle industry.
_______________________________________________________________________________________
Do you sell your product in foreign countries? ________
What percentage of your total receipts are from foreign sales? ______%
If your product is manufactured in a foreign country, does the foreign manufacturer have
insurance that will respond in the United States? ___________
Manufacturer app rev 6 2015
PROPERTY INFORMATION
(If more than 2 locations, please photocopy the below and complete for additional locations.)
Location # 1 Bldg. # _______ ________________________________________ Zip Code: ________
Protection Class ________ Inside City Limits? Yes No County (Name) ________________
Construction: Frame Joisted Masonry Non-Combustible _____________________
Year Built _______ Miles to Fire Station ________ Feet to Fire Hydrant ____________

Year of Updates (if over 25 years old) Wiring _____ Heating _______ Plumbing _____ Roof ______
Total Building Area _________ Insured’s Area________
Please check the following safeguards that you currently have:
Burglar Alarm Dead bolts locks on all doors Bars on all windows
Metal Doors Bikes locked together
when closed
VALUE COVERAGES AND LIMITS
Building $________ Coins_
______ Deductible______ Causes of Loss Basic Broad Special
Pers. Property $________ Coins_______ Deductible______ Causes of Loss Basic Broad Special
Business
Income $________ ____% of Coins (50% min) or mo. limit (1/3, 1/4 or 1/6 ) (circle one)
Extra Expense $________ (40% -80% -100%)
Minicomputer/
EDP
(100% coins)$________ Hardware $________ Software $________ Extra Expense $________
_______________________________________________________________________________________
Location #2 Bldg. # _______ ________________________________________ Zip Code: ________
Protection Class ________ Inside City Limits? Yes No County (Name) ________________
Construction: Frame Joisted Masonry Non-Combustible _____________________
Year Built _______ Miles to Fire Station ________ Feet to Fire Hydrant ____________

Year of Updates (if over 25 years old) Wiring _____ Heating _______ Plumbing _____ Roof ______
Total Building Area _________ Insured’s Area________
Please check the following safeguards that you currently have:
Burglar Alarm Dead bolts locks on all doors Bars on all windows
Metal Doors Bikes locked together when closed
VALUE COVERAGES AND LIMITS
Building $________ Coins_
______ Deductible______ Causes of Loss Basic Broad Special
Pers. Property $________ Coins_______ Deductible______ Causes of Loss Basic Broad Special
Business
Income $________ ____% of Coins (50% min) or mo. limit (1/3, 1/4 or 1/6 ) (circle one)
Extra Expense $________ (40% -80% -100%)
Minicomputer/
EDP
(100% coins) $________ Hardware $________ Software $________ Extra Expense $________
Manufacturer app rev 6 2015
REQUEST FOR FINANCIAL INFORMATIO
N
Explanation and Instructions: Information concerning the financial condition of an insured
location is essential to underwriters. Judgements regarding both eligibility and premium level are
made partially based on financial condition. Information submitted will be kept strictly
confidential.
Part I examines your trend in revenues and expenses.
Part II examines solvency by comparing your current assets to your current liabilities.
Part III examines both short and long term debt.
Part IV has to do with your credit history.
Complete Financial Statements including Balance Sheet and Income Statements may be
submitted as a substitute for this financial request.
PART I
LAST 12 MONTHS ENDING ____________
Gross Revenue ______________
Cost of Goods (not Labor) ______________
Gross Profit ______________
Cost of Labor ______________
Overhead Expenses ______________
Profit <Loss> after expenses ______________
PART II
Cash(on hand or in banks) ______________ Payable to Vendors ______________
Marketable Securities ______________ Taxes Payable (not F.I.T.) ______________
Accounts Receivable ______________ Income Taxes Payable ______________
Inventory ______________ Other Current Payables ______________
TOTAL OF ABOVE ______________ TOTAL OF ABOVE ______________
PART III PART IV
List Loans, Mortgages or any other Contract Debt Are you currently past due on payroll, sales
Amount Maturity Monthly or other taxes? Yes No
Date Payments
To Whom
___________ _________ _________ _________
Are you currently undergoing any form of
___________ _________ _________ _________ bankruptcy? Yes No
___________ _________ _________ _________
___________ _________ _________ _________
Who prepares your financial statements
___________ _________ _________ _________ and/or tax returns?_____________________
Questionnaire Must Be Completed for Insurance Quote.
Questionnaire Completed By:
Name__________________________________ Title ______________________________
Signature ______________________________ Date______________________________
Manufacturer app rev 6 2015
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Bicycle ManufacturerDistributor Product Questionnaire (Risk Placement Services, Inc.)

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Completed 30 July 2020

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