Heavy Vehicle & Equipment Questionnaire Template Page 2
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1
2Tune Up
______ %
Wash & Detail
______ %
Other *
______ %
*Describe work in detail:
th
4. Does applicant install, service or repair 5
Wheels?
Yes
No
If yes, what are the qualifications of the employees doing this work?
5. Are you and/or your mechanics ASE Certified?
Yes
No
If No, how many years of training and experience do you require? ___________________________________
6. Do you test drive extra-heavy trucks or truck tractors away from garage premises
Yes
No
on public roadways?
If yes, is at least one driver appropriately licensed with a CDL?
Yes
No
7. What parts, equipment, and accessories do you fabricate?
8. If applicant does FMCSA annual vehicle safety inspections, answer the following:
a] Does Inspector understand the FMCSA inspection criteria?
Yes
No
b] Has Inspector mastered the methods, procedures, tools and
Yes
No
equipment used when performing an inspection?
c] Has Inspector successfully completed a State or Federal training program
Yes
No
which qualifies him to perform commercial vehicle safety inspections?
d] Does Inspector have at least one year of training and/or experience consisting of:
participation in a manufacturer sponsored training program; or
experience as a mechanic or inspector:
1] in a motor carrier maintenance program; or
Yes
No
2] in a commercial garage; or
Yes
No
3] for a State or Federal government?
Yes
No
GENERAL FRAUD STATEMENT (Not applicable in all states)
Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading,
information concerning any fact material thereto, may be committing a fraudulent insurance act, and may be subject
to a civil penalty or fine.
SIGN AND DATE
PRODUCER’S SIGNATURE
DATE
APPLICANT’S PRINTED NAME
DATE
APPLICANT’S SIGNATURE
DATE
G1008-0715
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Parent category: Life