Fillable SPECIALTY VEHICLE Supplemental Garage & Auto Dealer Application (Risk Placement Services, Inc.)

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SPECIALTY VEHICLE Supplemental Garage & Auto Dealer Application (Risk Placement Services, Inc.)

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The SPECIALTY VEHICLE Supplemental Garage & Auto Dealer Application (Risk Placement Services, Inc.) form is 1 page long and contains:

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  • 3 check-boxes
  • 90 other fields

Country of origin: US
File type: PDF

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Name of Applicant (include DBA):
Private Passenger, Light & Medium Truck %
Cruiser/ Touring Motorcycles (i.e. Choppers, Trikes)
%
Sport/ Speed Motorcycles (i.e. Ninja, Ducati, Buell)
%
Dirt Bike, ATVs, UTVs, Snowmobile (other off-road vehicles)
%
Moped, Goped, Scooter - Licensed for public road use %
Moped, Goped, Scooter - Not Licensed for public road use %
Recreational Vehicle / Motor Coaches %
Watercraft or Boats (other than Jet Skis): Size:
feet %
Jet Skis %
Bucket Trucks, Cranes, Scissor Lifts %
Forestry or Logging Equipment %
Garbage Trucks %
Farm Tractors, Equipment or Implements
%
Contractors Equipment %
Heavy Trucks or Tractors (26,001 or more GVW)
%
Semi-Trailers, Livestock Trailer %
Tanker Truck or Trailers %
Utility Trailers, Service Trailers, Horse Trailers %
Busses (over 15 passenger capacity)
%
Shuttle Busses (15 passenger or less capacity)
%
School Busses %
Emergency Vehicles:
(check all that apply)
Fire Truck Ambulance Police Car %
OTHER (Provide complete description):
%
Provide % exposure in relation to the above specialty vehicles.
% Service/ Repair: Alignment, Steering or Front End Suspension
% Service/ Repair: Brakes
% Service/ Repair: Frame or Unibody Straightening
%
Service/ Repair: Pumps, Valves, Hoses of Tankers or Emergency Vehicles
% Service/ Repair: Medical or Lifesaving Equipment
% Service/ Repair: Gasoline Tanks Provide details:
% Service/ Repair: Hydraulic Systems Provide details:
% Service/ Repair: Structural Welding Provide details:
% Structurally Alter/ Convert Vehicles Provide details:
% Manufacture/ Fabricate: Auto Parts Provide details:
%
Custom Auto Assembly: Kit Car / Bike Building If yes, provide details below.
Do you:
Service/ Repair: Watercraft while in the water? Yes No
Service/ Repair: Watercraft hull? If yes, provide details: Yes No
Storage or parking space rental operations? If yes, provide receipts: Yes No
Diversion of traffic required? If yes, provide details: Yes No
Any out-of-state pickup or delivery requiring federal filing? Yes No
A
re autos taken to trade shows or special events? If yes, how many times per year: Yes No
Witness
ADDITIONAL INFORMATION
UNDERWRITING INFORMATION
INDICATE PERCENTAGE OF THE FOLLOWING TYPE OF AUTO EXPOSURES
Date Applicant's Signature
SPECIALTY VEHICLE
Supplemental
Garage & Auto Dealer Application is required in addition to this Supplemental
ALL QUESTIONS MUST BE ANSWERED IN FULL, SIGNED AND DATED BY THE APPLICANT.
Specialty Vehicle Supplemental CAG 7001 02/15
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SPECIALTY VEHICLE Supplemental Garage & Auto Dealer Application (Risk Placement Services, Inc.)

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Completed 30 July 2020

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