Fillable MOTORCYCLE SUPPLEMENTAL APPLICATION (Risk Placement Services, Inc.)

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MOTORCYCLE SUPPLEMENTAL APPLICATION (Risk Placement Services, Inc.)

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CGZ-SUPP-13 (11-16)
Page 1 of 2
MOTORCYCLE SUPPLEMENTAL APPLICATION
(To be completed in addition to CGZ-APP-6 Application for Garage Policy)
1. Applicant/Insured’s Name:
2. Years experience:
Motorcycle dealership/non-dealership owner:
Specifically with motorcycle: Sales Repair Rebuilding
3. What percentage of your operation involves:
Motorcycles
..............................
%
Go Karts ................................
% Watercraft ...............................
%
ATVs/UTVs
..............................
%
Dirt Bikes ...............................
% Other (Describe below) ..........
%
Mopeds/Scooters
.....................
%
Trikes .....................................
%
4. Do you permit off premises test drives? ...................................................................................................... Yes No
Is there a designated route taken? .............................................................................................................. Yes No
(If yes, provide map.)
5. Is anyone furnished a vehicle for personal use or allowed to take a vehicle home? .................................. Yes No
If yes, advise who is furnished and/or circumstances:
6. Is proof of motorcycle license and auto insurance checked prior to all test drives? ................................... Yes No
7. Do you sell or service bikes that cater to youthful drivers? ......................................................................... Yes No
8. Do you perform any customization? ............................................................................................................ Yes No
If so, what percentage? ............................................................................................................................... %
Provide details of work performed:
9. Do you perform structural alterations (Fork & Frame)? ............................................................................... Yes No
If so, what percentage? ............................................................................................................................... %
Provide details of work performed:
10. Do you convert bikes to trikes? ................................................................................................................... Yes No
If so, what percentage? ............................................................................................................................... %
Provide details of work performed:
CGZ-SUPP-13 (11-16)
Page 2 of 2
11. Do you manufacture bikes or bike parts or perform fabrication? ................................................................ Yes No
If so, what percentage? ............................................................................................................................... %
Provide details of work performed:
12. Do you perform assembly of bikes? ............................................................................................................ Yes No
If so, what percentage? ............................................................................................................................... %
Provide details of work performed:
13. Do you alter the original performance of manufacturer specifications? ...................................................... Yes No
If so, provide details:
14. Do you own or service any motorcycles for racing purposes? .................................................................... Yes No
15. Do you loan or rent motorcycles to others? ................................................................................................. Yes No
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 AND TITLE:
APPLICANT’S SIGNATURE: DATE:
(Must be signed by an authorized representative, owner, partner or executive officer)
PRODUCER’S SIGNATURE: DATE:
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MOTORCYCLE SUPPLEMENTAL APPLICATION (Risk Placement Services, Inc.)

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Completed 23 November 2020

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