MSA020 (06/16)
2) Do your operations include:
Yes No Taking autos to Trade Shows, Fairs or Special Events? If yes, how many per year? _________________________
Yes No Off-Premises test drives of motorcycles or any off-road vehicles?
If yes: Do you have a specific route? Yes No
Do you accompany using an owned vehicle? Yes No
Where do you go? ________________________________________
How far do you go? _______________________________________
Yes No Furnished/Personal use of Motorcycle or other off road vehicle?
Yes No Any operations at a marina, or while watercraft is in the water?
Yes No Repairs to kitchen appliances, electrical wiring, or heating/cooling systems for RVs, Campers, Motorhomes or Motor
Coaches?
If yes, what percentage of your operation? _______ %
Yes No Uninstalled parts, accessories or other similar sales? If yes, complete Annual Receipts below:
Accessory sales $ _________ Uninstalled Parts Sales (New) $ __________
Uninstalled Parts Sales (Used) $ __________ Other (describe) __________/ $ _________
3) Where do you conduct operations?
Your Premises ______%
Customer’s Location ______%
Roadside ______%
Other: ________________ ______%
4) Are your mechanics ASE Certified? Yes No
If no, how many years of related experience do you require? __________________
5) Do you test drive any vehicles over 26,000 off-premises? Yes No
If yes, do your drivers possess CDL licenses? Yes No
6) If you do FMCSA annual vehicle safety inspections, answer the following:
a. Does Inspector understand the FMCSA inspection criteria? Yes No
b. Has Inspector mastered the methods, procedures, tools and equipment
Used when performing an inspection? Yes No
c. Has Inspector successfully completed a State or Federal training program
which qualifies him/her to perform commercial vehicle safety inspections? Yes No
d. Does Inspector have at least 1 year of training and/or experience consisting of:
• Participation in a manufacturer sponsored training program; or
• Experience as a mechanic or inspector:
o In a motor carrier maintenance program; or
o In a commercial garage; or
o For a State or Federal Government? Yes No
Additional Information: _________________________________________________________________________________________
This questionnaire does not bind the Application nor the Company to complete the insurance, but it is agreed that the information contained
herein shall be part of the basis of the contract should a policy be issued. By signing you are hereby certifying that all information is
accurate to the best of your knowledge.
_______________________________ _____________/__________________________________________
Signature of Agent Date Signature of Applicant
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