CGZ-SUPP-14 (11-16) Page 1 of 1
TIRE SALES AND SERVICE SUPPLEMENTAL APPLICATION
(To be completed in addition to CGZ-APP-6 Application for Garage Policy)
1. What percentage of your garage operations are the sales of tires? ........................................................... %
Type % New % Used Type % New % Used
Private Passenger Busses
Motorcycle/ATV Other Equipment
Heavy Trucks (over 30,000 GVW) Other, describe below
(In the chart above, percentages must equal one hundred percent [100%])
Other:
2. Do you sell tires that were manufactured more than five years ago? ......................................................... Yes No
If yes, provide percent of sales to total tire sales: ....................................................................................... %
3. Are all employees trained how to identify the manufacturer’s stamp to determine the age of tires? .......... Yes No
4. Do you service or sell recapped or retread tires? ........................................................................................ Yes No
If yes, provide percent of sales to total tire sales: ....................................................................................... %
5. Do you service or sell vulcanized tires? ...................................................................................................... Yes No
If yes, explain:
If yes, provide percent of sales to total tire sales: ....................................................................................... %
6. Do you service or sell re-grooved or siped tires? ........................................................................................ Yes No
If yes, provide percent of sales to total tire sales: ....................................................................................... %
7. Do you repair or fix flat tires for heavy trucks? ............................................................................................ Yes No
a. If yes, do you use a safety cage when working with split rim or locking ring wheels? .......................... Yes No
b. Describe your quality assurance precautions to ensure tires are properly installed and inflated:
Refer to the application form for state fraud warnings.
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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signature
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