Name
Submission/Policy Number:
Proposed Effective Dates: FROM:
TO:
INSURANCE HISTORY AND LOSS EXPERIENCE
Yes
No
Effective Dates
From - To
Prior Carrier Name
Policy Number
#
Losses
Loss Amount
Description of Loss
LOCATION OF PREMISE
Location
Address
Classification*
Truckers
Warehouses
Auto Repair & Service
Truckers
Warehouses
Auto Repair & Service
Truckers
Warehouses
Auto Repair & Service
X
X
X
T-240 (9/10)
UNDERWRITING INFORMATION
Yes
No
Yes
No
Page 1 of 4
1
2
3
© 2010 The Travelers Indemnity Company. All rights reserved.
COMMERCIAL AUTO
GENERAL LIABILITY APPLICATION SUPPLEMENT
This application must be attached to the Commercial Auto Application.
1.
Has insurance company canceled or nonrenewed your policy is the last 3 years?
(Missouri Applicants - Do not
answer this question.)
Yes No If yes, explain:
2.
Prior years insurance under business name:
3.
Have there been any General Liability losses in the last 3 years?
If yes, indicate losses below:
*Must have Truckers (99793) class in order to select Warehouses NOC (99938) or Automobile Repair or Services
Shop (10073) class(es).
1.
Fully describe the insured's operation.
2.
Do you have any operations other than trucking, such as:
3.
Do you generate income from other activities besides the operation of the trucks?
4.
Do you sign any contracts requiring the insured to assume the liability of another party?
5.
Do you sign any contracts requiring other parties to assume liability?
6.
Do you use mobile equipment on or off premises such as forklifts, backhoes or hand trucks?
7.
Do you loan or rent any machinery, equipment or motor vehicles to others?
8.
Are any of your vehicles unlicensed or not covered under an auto policy?
9.
Are there independent contractors hauling on your behalf?
If yes, do they carry General Liability coverage with limits equal to those being requested?
10.
Identify type of fire protection (functioning and properly maintained):
Sprinkler System
Smoke Detectors
Fire Extinguishers
Other - Describe:
11.
If you perform services on air conditioning/refrigeration units, do mechanics hold required certification
where required by law?
12.
Identify type of security protection, if any:
Fenced
Security Cameras
Guard Dogs
Security Guards/Service
Other - Describe:
a.
Storage of goods of others (warehousing)
b.
Repair of vehicles or goods of others
c.
Storage of vehicles of others
d.
Space leased to others
e.
Sale of fuel or other products
f.
Freight forwarding, consolidation, or brokering
g.
Any sporting or social events sponsored
h.
Farming operations
i.
Any other business activities located at same
premises
j.
Towing - Owned or for Others
T-240 (9/10)
Complete the following questions ONLY if selecting Warehouses NOC Class
Yes
No
Complete the following questions ONLY if selecting Auto Repair & Services Shop Class
Yes
No
Yes
No
Yes
No
Page 2 of 4
N/A
Yes
No
© 2010 The Travelers Indemnity Company. All rights reserved.
Yes
No
15.
Number of years operating a Warehouse operation
16.
Indicate type of goods stored:
Cold/Refrigerated Products - what percent is cold storage?
%
Containerized Freight
Public (pay charges to store)
Private (storing own goods)
Bonded (imported goods)
Other - describe:
17.
Does the warehouse have sales or sell merchandise to the public?
18.
Is the warehouse locked after hours?
19.
Are goods delivered after hours to warehouse?
20.
Do you have procedures in place to assure proper warehousing of refrigerated goods?
21.
Do you have any railroad sidetrack agreements?
22.
Number of years operating garage/repair shop:
23.
Revenue generated from performing service of vehicles other than company owned:
Location 1: $ Location 2: $ Location 3: $
# Units Serviced Annually
24.
Indicate percentage of work on the following:
Truck Tractors
%
Semi-Trailers
%
Refrigerated Vans
%
Tank Trailers
%
Boom Trucks/Bucket Trucks
%
Service or Tow Trucks
%
Farm Equipment
%
Construction Equipment
%
Other
%
25.
Indicate percentage of work performed off premises:
%
26.
Hours of operation for repair/service operation
Number of days
27.
Is the repair/service facility locked after hours?
28.
Indicate percentage of work that is:
Body & Paint
%
Brakes
%
Engine Overhaul
%
Fabrication, Rebuild, Weld
%
FMCSA Safety Inspection
%
Hydraulics
%
5th Wheel
%
Lube & Oil
%
Power Train
%
Radiator
%
Refrigeration Unit
%
Repair Tank Trailers (external)
%
Subcontracted out to others
%
Hitches
%
Frame
%
Suspension
%
Tank Cleaning
%
Tire Repair or Replacement
%
Tune Up
%
Wash & Detail
%
Tire Recapping
%
29.
Are the mechanics ASE certified?
If no, number of years of training and experience you require:
30.
If employees drive extra-heavy trucks, truck tractors and semi-trailers away from the garage premises on public
roadways, do they have the required Commercial Driver's License (CDL)?
31.
If you complete FMCSA annual vehicle inspections:
a.
Does the inspector understand the FMCSA inspection criteria?
b.
Has inspector mastered the methods, procedures, tools and equipment when performing an inspection?
c.
Has inspector successfully completed a State or Federal training program which qualifies him to perform
commercial vehicle safety inspections?
d.
Does inspector have at least one year of training and/or experience consisting of:
(1)
Participation in a manufacturing sponsored training program; or
(2)
Experience as a mechanic or inspector:
-
In a motor carrier maintenance program; or
-
In a commercial garage; or
-
For a State or Federal government
13.
Are parking facilities and common areas free from defects and adequately lighted?
14.
Are visitors allowed on the premises?
Visitors on a daily basis: Average
Maximum
Explain all YES answers:
No
Yes
T-240 (9/10)
No
Yes
Page 3 of 4
Yes
No
© 2010 The Travelers Indemnity Company. All rights reserved.
32.
Are any vehicles held for sale at any of the locations?
33.
Do you sell new tires?
34.
Do you sell used tires?
35.
Do you recap tires?
36.
Do you have a parts store?
37.
Do you operate a salvage yard?
38.
Number of service bays
39.
Do you have hoists/lifts?
40.
Is customer's vehicle stored overnight in an enclosed or locked location?
41.
Are keys stored in a secure location where access is restricted to authorized personnel only?
42.
Are customers allowed in service areas?
If yes, are they escorted?
43.
Are signs posted to warn customers that shop is not responsible for any items left inside their vehicles?
44.
Do you loan or lease vehicles to customers while their autos are being serviced?
If yes, how often?
45.
Do you repossess autos?
If yes, do you contract it out?
46.
Is any part of your operation a self-service auto repair shop?
47.
Do you have any unused underground storage tanks?
48.
Are gas pumps available to the public?
49.
Do you sub-contract repair work to others?
If yes, do you secure certificates of insurance?
50.
Are any guarantees or warranties offered on parts or labor for jobs performed?
51.
Indicate steps in place to ensure that proper repairs are made and the vehicle is safe to return to the road:
Post Service Checklist
Service Manager Review
Test Drive
Customer Pre-Approval of Repairs
52.
How are used tires, automotive fluids, batteries, motor oil, and soiled uniforms and rags disposed of?
53.
How are solvents and flammables stored and properly disposed of?
54.
What hazardous materials are stored on premises?
55.
Do you work on vehicles that have been involved in accidents?
If yes, what precautions are taken to protect workers from exposure to bloodborne pathogens?
56.
Indicate parts, equipment, and accessories you fabricate:
AUTO REPAIR AND SERVICE SHOP EMPLOYEES
(Last, First, Middle)
Date of Birth
License Number
State
# Violations
Past 3 Years
Minor
Major
#
Name
Accidents
Page 4 of 4
LIMITS
EMPLOYERS LIABILITY (STOP GAP) COVERAGE (Applicable in ND, OH, WA and WY only)
W.C. Carrier
W.C. Policy #
W.C. Effective Date
EMPLOYEE AND PAYROLL INFORMATION
Total Number
Payroll Amount
Payroll
Location
123123
T-240 (9/10)
© 2010 The Travelers Indemnity Company. All rights reserved.
APPLICANT'S SIGNATURE
DATE
General Aggregate
Products-Completed Operations Aggregate
Personal & Advertising Injury**
Each Occurrence**
Damage to Premises Rented to You
Medical Expense (any one person)
$
$
$
$
$
$
**These limits should be the same as the Auto Combined Single Limit or the Auto Per Accident Limit.
Limits for Bodily Injury Accident each Accident/Disease each Employee/Disease per Policy (Disease per policy limit can
not exceed GL Aggregate Limit)
$100,000/$100,000/$500,000 $500,000/$500,000/$500,000
$1,000,000/$1,000,000/$1,000,000
$2,000,000/$2,000,000/$2,000,000 (Truckers Class Only)
Executive Officers/Individual Insured and
Co-Partners
Outside Sales, mechanics (for owned
equipment), yard employees, terminal
employees, dispatcher
Clerical, inside sales, drivers
Warehouse employees
Other:
Total Payroll
click to sign
signature
click to edit
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome