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HEAVY TRUCK, BUS AND EQUIPMENT SUPPLEMENTAL APPLICATION (Risk Placement Services, Inc.)

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CGZ-SUPP-10 (11-16) Page 1 of 3
HEAVY TRUCK, BUS AND EQUIPMENT SUPPLEMENTAL APPLICATION
(To be completed in addition to CGZ-APP-6 Application for Garage Policy)
ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPL
ICABLE” (N/A)
Name of Applicant:
1. TYPES OF VEHICLES (MUST = 100%)
Private Passenger Types and Light Trucks: ......................................................................................... %
Heavy Trucks (over GVW 20,001): ....................................................................................................... %
Contractors/Construction Equipment: ................................................................................................... %
List the types:
Dump Trucks: ........................................................................................................................................ %
Bucket Truck/Cherry Picker (or other trucks with a lifting apparatus): .................................................. %
Buses: ................................................................................................................................................... %
List the passenger capacity:
School Buses: ....................................................................................................................................... %
Other, list the types:
Trailer: ................................................................................................................................................... %
List the types of trailers:
Farm Equipment: ................................................................................................................................... %
Any non-auto implements? ................................................................................................................... Yes No
Other—Description: ............... %
2. TYPES OF REPAIRS (MUST = 100%)
Alignment, Steering or Suspension: ...................................................................................................... %
Body Work: ............................................................................................................................................ %
Brakes: .................................................................................................................................................. %
Engine: .................................................................................................................................................. %
Minor Major Rebuilding
Fifth Wheel Installation/Repair: ............................................................................................................. %
Framework: ........................................................................................................................................... %
Welding: .......................................................................................................................................... %
Cutting: ........................................................................................................................................... %
Stretching: ....................................................................................................................................... %
Straightening: .................................................................................................................................. %
CGZ-SUPP-10 (11-16) Page 2 of 3
Hydraulic Work: ..................................................................................................................................... %
What does the hydraulic component operate?
Lifts: ....................................................................................................................................................... %
Describe lifts:
Lube and Oil: ......................................................................................................................................... %
Manufacturing/Fabrication:.................................................................................................................... %
What is produced?
Painting: ................................................................................................................................................ %
Paint booth: ........................................................................................................................................... Yes No
If yes, does entire vehicle fit inside? ..................................................................................................... Yes No
Refrigeration (Refrigeration of the cargo hold):..................................................................................... %
Split Rim or locking wheel assemblies: ................................................................................................. Yes No
Do you have only the appropriately trained workers and appropriate equipment for service split rim
and locking wheel assemblies? ............................................................................................................
Yes No
Tanker: .................................................................................................................................................. %
What products do the tankers hold?
Tires:
Sales:
New: ................................................................................................................................................ %
Used: .............................................................................................................................................. %
Repair: ................................................................................................................................................... %
Are tires over five years old?................................................................................................................. Yes No
Any recapping/retreading? .................................................................................................................... Yes No
Do you service or sell vulcanized/siped/regrooved tires? ..................................................................... Yes No
Describe your quality assurance precautions to ensure tires are properly installed and inflated:
Trailer Hitch Installation/Repair: ............................................................................................................ %
Bolt on Weld on
Trailer Repair (box and cargo only, see above for tanker trailers):....................................................... %
Transmission (including clutch and differential work): .......................................................................... %
Tune-Up: ............................................................................................................................................... %
Wash/Detail: .......................................................................................................................................... %
Interior Only Exterior Only Interior and Exterior
Welding: ................................................................................................................................................ %
What exactly is welded?
Other—Description required: ............... %
Are you authorized to perform USDOT/FMCSA safety inspections: .................................................... Yes No
If yes, how many safety inspections do you perform a: Week Month Year: .......................
1. Has Inspector successfully completed a State or Federal training program which qualifies
him/her to perform commercial vehicle safety inspections? ...........................................................
Yes No
CGZ-SUPP-10 (11-16) Page 3 of 3
2. Does Inspector have at least one year of training and/or experience consisting of: ...................... Yes No
a. Participation in a manufacturer sponsored training program;
b. Experience as mechanic or inspector; or
i. In a motor carrier maintenance program; or
ii. In a commercial garage; or
iii. For a State or Federal government?
3. LOCATIONS WHERE YOU CONDUCT OPERATIONS
At your premises: .................................................................................................................................. %
At customers’ premises: ........................................................................................................................ %
On the roadside: .................................................................................................................................... %
Do you pick up or deliver customer autos? ........................................................................................... Yes No
Does the owner have a CDL (commercial driver license)? ................................................................... Yes No
Do all drivers have a CDL (commercial driver license)? ....................................................................... Yes No
REMARKS: (use this section to expand on answers that need further explanation)
Refer to the application form for state fraud warnings.
Applicant or authorized representative of the applicant, confirm and warrant that all of the above are true and accurate
representations of my garage operation.
APPLICANT’S NAME/TITLE:
APPLICANT’S SIGNATURE: DATE:
(Must be signed by an authorized representative, owner, partner or executive officer)
PRODUCER’S NAME: DATE:
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Completed 23 November 2020

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