Automobile Dismantlers Supplemental Application Form
Download a blank fillable Automobile Dismantlers Supplemental Application Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Automobile Dismantlers Supplemental Application Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4Deerfield Insurance Company
Agent Name
Evanston Insurance Company
Agent Street
Essex Insurance Company
Agent City, State, Zip
Markel American Insurance Company
Markel Insurance Company
Associated International Insurance Company
AUTOMOBILE DISMANTLERS SUPPLEMENTAL APPLICATION
(To be attached to ACORD applications)
Date of Application: _____________
NAME OF APPLICANT: _______________________________________________________________________________
ADDRESS: _________________________________CITY: _____________________ STATE: _______ ZIP: _________
Website: ______________________________
Proposed Effective Date: _____________
OPERATIONS
1. Please check below all services provided including percentage of revenue where indicated.
Used parts
______%
New auto parts _____%
Dealer plates - # of: ___
U-Pull-It
_____%
Auto body work
______%
Used car sales _____%
Impound lot operations
Engine rebuilding ___ %
Towing for others including
Auto repair, installation,
Tire service or mounting
Windshield replacement/
roadside recovery _____%
service of parts _____%
_____%
repair
_____%
Car crushing by own
Car crushing contracted
Own/sponsor race car(s)
Other: ______________
equipment
______%
to others
_____%
Owner(s) purchase a personal auto policy for family exposures
Total - All Operations 100%
2. Please check below all that apply:
Vehicles are not stacked over six high.
Customers/visitors are escorted at all times.
Average more than 300 tires stored in the yard.
Customers are allowed to remove parts from the yard.
Warranties are provided for your parts. (Attach copy)
Customers are not allowed to work on their cars in the yard.
UL approved ABC fire extinguishers are in place.
Customers are charged to enter the yard.
UL approved spray booth with sprinkler and safety lights.
Spray painting not allowed outside the booth or in the open.
3. Are you a current member in good standing with any professional automobile dismantling associations?
Yes
No
If Yes, name of association(s): ______________________________________________________________________
Are you an ARA Certified Automotive Recycler (CAR)?
Yes
No
If Yes, date of latest certification: ________________
4. If you contract companies to transport your crushed vehicles, do you obtain and review Certificates of Insurance?
N/A
Yes
No
5. Describe your fuel tank removal and drainage procedures. (You may skip this question if CAR Certified) ____________
_______________________________________________________________________________________________
6. Describe your airbag deployment or removal procedures. (You may skip this question if CAR Certified) ____________
_______________________________________________________________________________________________
MAIL 014 02 12
Page 1 of 4
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business