Salvage Yard Supplemental Application - AllRisks
*Please visit submit-a-risk or contact your current All Risks, Ltd. producer to submit applications.
Salvage Yard Supplemental Application
1. Proposed First Named Insured & Other Named Insured(s):
2. Mailing Address 3. Website Address:
Street
City
County
State
Zip Code
4. Contact for Inspection/Audit: Name:
Phone No.:
5. Effective Date Desired: From:
To:
TermDesi red
6. Years in Business:
PREVIOUS INSURER & LOSS HISTORY ? Attach separate sheet if necessary
See Loss Runs Attached
Missouri Applicants: DO NOT answer this question. Has insurance of this type been cancelled, refused, or nonrenewed by any company during the past 3 years?
Yes No
If Yes, give name of company, date, and reason:
Indicate all claims or losses (regardless of fault and whether or not insured) or occurrences that may give rise to claims for the
past 3 years:
Losses/
Year
Carrier
Policy Number
Premium Coverage
$ Amount
Description of Loss
BUSINESS INFORMATION 7. Is the salvage yard fully fenced? 8. Do you allow customers in the yard unaccompanied? 9. Do you allow customers to pull their own parts?
If yes, are they accompanied by an employee? 10. Do you have any animals on the premises? 11. Do you sell used parts and accessories without installing them?
If yes, annual sales receipts: $ 12. Do you alter or rebuild any salvaged parts? 13. Do you provide any warranties or guarantees on parts sold? 14. Do your invoices and/or sales receipts state parts are sold "as-is"? 15. Do you use these used parts in your repair operations? 16. Do you stack vehicles?
If yes, indicate how high: 17. Do you have a car crusher?
If yes, advise the safety precautions used:
18. Do you sell salvaged titled autos? 19. If you have auto sales, are they performed at a separate location?
If no, how are the autos held for sale separated from the salvage operations:
20. Annual Sales/Receipts: $
Salvage Yard Supplemental Application - 02.17
Yes
No
Page 1 of 2
21. Do you perform any welding?
If yes, indicate:
%
22. Do you distribute any foreign manufactured parts?If
yes, provide a list of products:
Yes
No
FRAUD STATEMENTS
FLORIDA: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
LOUISIANA and MAINE: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.
Refer to the Core Application for all Fraud Statements.
IMPORTANT NOTICE
DECLARATION
I DECLARE THAT THE STATEMENTS MADE IN THIS APPLICATION ARE COMPLETE AND TRUE.
As part of our underwriting procedures, a routine inquiry may be made to obtain applicable information concerning character, general reputation, and credit history. Upon your written request, additional information as to the nature and scope of the report, if one is made, will be provided.
SIGNATURES
Applicant Signature
Title
Date
Producer Signature
Date
Producer Name and Address
Salvage Yard Supplemental Application - 02.17
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