Fillable WdZK>hDE&h>K/> KWZd/KE^ www .cfins.c om PETROLEUM 1. Provide (Crum & Forster Insurance)

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Page 1
1. Provide gallons sold by type of customer
PETROLEUM
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Type of customer Petroleum Fuel Oil Other/Type
Retail – sold to personal end users
Commercial – sold to commercial end users
Wholesale – sold to other dealers or
distributors for resale
Drop Shipped – picked up from non-owned
terminal and delivered direct to customer
Brokerage – paper transaction only – no
physical possession of product
2. Do you have bulk plant storage? (NON-LPG) Please List Below:
Address
Type of Fuel
Above Ground/Gallons
Below Ground/Gallons
Capacity
Is the tank diked?
Yes No
Yes No
Yes No
Yes No
What type of material is
dike and floor?
Fenced?
Yes No
Yes No
Yes No
Yes No
Type of leak monitoring
system
3. Do you have a security plan in conformance with DOT HM 232? Yes No
4. Do you have an EPA approved Spill Prevention Control and Countermeasure Plan in place? Yes No
5. Do you do any loading/unloading from any kind of watercraft or barges? Yes No
6. Do you do any direct fueling of aircraft or watercraft? Yes No
7. Are all delivery vehicles equipped with spill containment equipment? Yes No
8. Do you have any agreements in place with HAZMAT cleanup contractors for spills in transit? Yes No
Page 2
9. Are all delivery vehicles equipped with emergency communication devices and emergency phone numbers for
HAZMAT cleanup contractor and claim reporting? Yes No
10. For gasoline products, are all vehicles or loading racks equipped with deep spout tanks or bottom filling tanks?
Yes No
HOME HEATING OIL
1. For a basement fill, do you confirm the fill line is connected to the tank prior to each fill? Yes No
2. For a basement fill, do you confirm there is a working vent/whistle alarm in place near the fill pipe?
Yes No
3. If a fill line is no longer in use, has it been properly disabled to prevent filing? Yes No
4. Do you have a “No Whistle – No Fill” policy? Yes No
Page 3
1. Do you have a C Store location? Please list below.
CONVENIENCE STORE
www
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om
Address
Hours of Operation
Inside or Outside Surveillance Cameras?
Inside
Outside
Both
None
Inside
Outside
Both
None
Inside
Outside
Both
None
Any check cashing for a fee operations?
Yes No
Yes No
Yes No
ATM’s located inside or outside?
Inside
Outside
Both
None
Inside
Outside
Both
None
Inside
Outside
Both
None
Car wash automatic or manual (wand/brush
operated by customer)?
Auto
Manual
None
Auto
Manual
None
Auto
Manual
None
Any propane bottle exchange or bottle fill
operations?
Bottle Exchange
Bottle Fill
None
Bottle Exchange
Bottle Fill
None
Bottle Exchange
Bottle Fill
None
What are the average/max. amounts of cash
on the premises?
Avg.
Max
Avg.
Max
Avg.
Max
Are there any deep fat fryers for
cooking?
If yes,
- Is there a automatic extinguishing system
in hood, duct, and covering cooking
surfaces?
- Is there a thermostatic control with auto-
matic fuel shutoff?
- Have you contracted for cleaning of the
hood, ducts filters?
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
What type of alcohol is sold?
Beer
Wine
Liquor
Beer
Wine
Liquor
Beer
Wine
Liquor
Alcohol annual receipts $
Page 4
2. Have arrangements been made for prompt removal of snow and ice? Yes No
If yes, describe:
3. Are any firearms kept or brought on to the premises by employees? Yes No
If yes, describe:
4. Are there any machines (games of chance) on any of the premises that award money, or prizes, points/tokens that can
be redeemed for merchandise? Yes No
If yes, describe:
5. Do any of the premises have showers or sleeping facilities? Yes No
If yes, describe:
6. Do any of the premises sell fireworks or allow fireworks to be sold by others at any time during the year?
Yes No
If yes, describe:
7. Do you sublease any part of the premises to another business operation (motor vehicle repair/sales, restaurants,
Laundromats, etc.)? Yes No
If yes, do you get a Certificate of Insurance? Yes No
8. Comments on frequency of deposits, use of time lock safes, and any measures used to reduce crime exposure:
9. What type of training do employees receive in age verification for alcohol and cigarette sales?
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Completed 13 July 2021

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