Fillable New Renewal Rewrite Service Station Questionnaire (Crum & Forster Insurance)

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New Renewal Rewrite Service Station Questionnaire (Crum & Forster Insurance)

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MI 16 001 07 28
824 Front Street
Conway, AR 72032
Toll Free 800.233.2398
Fax 501.450.6916
Applicant Information
Description of Operation
Service Station Questionnaire
□ New □ Renewal □ Rewrite
Named Insured Fed ID Number
DBA Producers Name & Address
Mailing Address
City, State, Zip and County
Proposed Term
________ to ________
□ Bound □ Not Bound
□ Corporation
□ Partnership
□ Individual
□ LLC
Telephone Number Inspection Contact Name
□ Gasoline – Brand       
Hours of
Operation
_____ to _____
□ 24 Hour
Years Experience
      
Yrs. at Location
      
Breakdown of ANNUAL Sales / Gallons
□ Full Self □ Auto Body
Gas (gal) Repair ($)
□ Mini-mart □ Carwash
Mini-mart ($) Car Wash ($)
□ Repairs □ Propane Sales
Liquor ($) Restaurant/Deli ($)
□ Other            
Propane (gal) Other ($)
Location #
Address Building Is Construction Prop Terr. Fire Dist. Prot. Class Bldg Age Sq. Ft.
City, ST Zip
□ Owned □ Leased
Property Deductible □ □ $1,000 □ Other        
□ Broad Form Property Endt. Requested
Building #1 □ Theft □ X-Theft
$ Gasoline $
Building #2 (Occupancy)       $ Car Wash Equipment $
□ Replacement Cost □ Actual Cash Value
Glass Coverage # of Bays  $
□ 100 □ 250
Contents $ Vehicle Building Damage $ $500
Pumps $ Accounts Receivable $
Tanks $ Employee Tools
Canopy $ EDP Coverage
Hoses & Nozzles $ I.M. Leased Property Floater
Signs □ Attached
□ Unattached
$
$
□ Legal Liability
□ Fire Legal Liability
$
Bus. Income (Check)
□ Ext Expense
□ Off Prem. Ext.
□ O.H. Power
□ Comm. Supp
□ Power & Water
$
□ 1/3
□ 1/4
□ 1/6
Robbery Inside
Robbery Outside
Safe Burglary
Employee Dishonesty
(# of EE’s)
$
$
$
$
Deductible
$
General Liability Limit Aggregate Limit Liability Deductible Liquor Liability
□ Hired Auto
□ $500,000 □ $1,000,000 □ 1X □ 2X □ 3X □ 500 □ 1000 □ Yes □ No □ Non-Owned Auto
Garage Keepers Limit Garage Keepers Type Comp Ded. Coll Ded.
$
□ Legal □ Excess □ Primary □ 500 □ 1,000 □ 2,000 □ 500 □ 1,000 □ 2,000
MI 16 001 07 28
Policy Term Company Policy Number Premium
Date of Loss Description of Loss Paid/Reserve
Insurance Policy History
Additional Interests
Underwriting Information – Only complete those sections that apply to the account
Name & Address of Additional Interest
1.
□ Owner of Premise □ Addtl Insd. – Franchisor
□ Addtl. Insd. – Lessor □ Mortgagee
□ Loss Payee □ Addl. Insd. – Leased Equipment    
□ Addtl Insd. - Auto
                  
2.
□ Owner of Premise □ Addtl Insd. – Franchisor
□ Addtl. Insd. – Lessor □ Mortgagee
□ Loss Payee □ Addl. Insd. – Leased Equipment    
□ Addtl Insd. - Auto
                  
General Operations – Must be completed Hours of Operation: _______ to _______ □ 24 Hours
a. If building is 25 years or older, provide dates of last electrical, plumbing, and roong updates to building.
MONTH/YEAR _______/________
Yes No Question
1.
□ □
Any policy cancelled or non-renewed during the past 3 years? If yes, please explain in cover letter.
2.
Number of re extinguishers _______. Service within the past 12 months? □ Yes □ No
3.
□ □
Any cracks or broken pavement?
4.
□ □
Any guard dogs on premise?
5.
□ □
Age of Underground Storage Tanks? ____________ If over 10 years old, provide details about updates.
6.
□ □
Any rearms on premise?
7.
□ □
Is the applicant within one to ve miles of the ocean? If yes, need distance to ocean, bay or tributary.
_______________
a. Does the applicant or others operate any other business on premise?
If yes, describe operations                             
b. Does the applicant operate any other business operations under the named insured which we are not
insuring?
If yes, provide details                               
8.
□ □
MI 16 001 07 28
Yes No Question
9.
□ □
Does tenant have insurance providing limits equal to our insured and naming our insured as additional
insured?
IF NO, RISK IS INELIGIBLE. Provide tenant’s insurance company _______________________________, limits of
liability ________________, re legal liability limit ____________________, Lessor shown as additional insured
on tenant’s policy? □ Yes □ No
10.
□ □
Is business auto coverage required? If so, complete Business Auto Acord Application and include with
submission.
11.
□ □
Does the applicant □ rell LPG tanks or □ bottle exchange? If rell, complete the LPG supplemental
application. If bottle exchange, who is the provider? ________________________________________________
12.
□ □
Does the applicant rent trucks (Ryder, U-Haul)? If yes, please explain in cover letter.
13.
□ □
Do diesel receipts exceed 15% of total gas sales? (If yes, complete Truck Stop Supplemental Application)
14.
□ □
Does the applicant operate tow trucks? If yes, how many? _____(Complete Tow Truck Supplemental Appl.)
15. What is the distance to nearest paid re department?
16. What is the distance to nearest re hydrant?
17. Are there any of the following exposures? If yes, please provide details and annual sales.
□ □
Check Cashing Operations Details Annual Sales
□ □
Money Order Sales Details Annual Sales
□ □
Western Union Service Details Annual Sales
Service Station with Repair and Auto Repair Garages – Complete only if applicant repairs or services vehicles
18.
□ □
Does the applicant do body work or spray painting?
(If yes, complete the body shop supplemental application)
19.
□ □
Are mechanics certied? Is yes, by whom _________________ How many are certied? ___________________
20.
□ □
Does the applicant modify vehicles (e.g. Sunroofs, Conversions)?
21.
□ □
Any repair of trucks in excess of 20,000 GVW? If yes, provide largest truck in GVW ____________________.
22.
□ □
Does the applicant rebuild engines or transmissions? If yes, how many a year? _______________
23.
□ □
Does the applicant sell new, used, or recapped tires? If YES, list annual sales - NEW $________,
USED $________, RECAPPED $______. If any used and/or recapped tire sales - RISK IS NOT ELIGIBLE.
24.
□ □
Does the applicant work on high value sports cars or RV’s? If yes, provide details in cover letter.
25.
□ □
Are used shop towels and all ammables stored in approved metal containers?
26.
□ □
Any vehicles stored outside during non-working hours that are not enclosed by a locked 6-foot fence?
27.
Avg. # of customer’s vehicles stored on the premise:
During working hours ______ During non-working hours ______
28.
□ □
Is there any off-premise or street parking of customer’s vehicles?
29.
Are nal inspections and road tests done by □ Supervisor □ Technicians
(Are they documented?) □ Yes □ No
Quick Lube Account – Complete only if account is considered a Quick Lube
30. Does the account have “Pits” or does the account utilize Lifts to change the oil?
31.
□ □
If the accounts has “Pits”, are nets present over the “Pits”
32.
□ □
If the account has “Pits”, are re extinguishers present above and below?
33.
□ □
Do the customers drive their own vehicles into/out of bays?
34.
□ □
Does a above average customer waiting area exist on this account?
35.
□ □
Are there signs stating “No customer access in work areas”?
MI 16 001 07 28
Crime General – Must be completed
Yes No Question
36.
□ □
Is there an alarm system?
If yes, please indicate what type □ Local □ Central Station Serviced by ____________________________
37.
□ □
Do all exterior doors have double cylinder deadbolts? If No, please explain. ___________________________
38.
□ □
Are receipts taken home at night? If yes, describe protection _________________________________________
Crime - Service Stations – Complete only if Service Station exposure exists
39.
Restrooms are located □ Inside □ Outside and are kept □ Locked □ Unlocked
40.
□ □
Does this location have security bars on the doors and windows?
41.
The attendant is protected by:
□ TV Camera □ Cash Drawer □ Panic Button □ Bullet Resistant Glass □ Unprotected
42.
□ □
Does city police regularly patrol the neighborhood?
43.
□ □
Are drop safes used with signs posted to this effect? Explain if “No”. __________________________________
44.
□ □
Are deposits made daily including weekends? Explain if “No”. _______________________________________
Liquor Liability – Complete only if applicant sells liquor
45.
□ □
Does the applicant sell any liquor other than beer, ale and wine?
If yes indicate sales of hard liquor $_________________
46.
□ □
Has the applicant’s liquor license ever been suspended or revoked?
47.
□ □
Have all employees been trained on the sale of alcohol including how to handle intoxicated customers
and minors?
48.
□ □
Are signs displayed on premise prohibiting the on-premise consumption of alcoholic beverages?
Explain if “No”. __________________________________________________________________________________
Car Wash – Complete only if accounts has a Car Wash
49.
Is Car Wash: □ Full Service or □ Self Service
(If Full Service, Complete Full Service Supplemental Application)
50.
Type of Car Wash: □ Brush □ Brushless □ Wand
51.
□ □
Are physical barriers erected & signs posted to prohibit foot trafc to wash area?
52.
□ □
Do the employees have clear visibility of wash area and are trained to shut off the wash if foot trafc is
observed?
53.
How often does OWNER inspect the car wash equipment?
□ Weekly □ Monthly □ Bi-Monthly □ Semi-Annually
54.
How often does MANUFACTURER inspect the car wash equipment?
□ Weekly □ Monthly □ Bi-Monthly □ Semi-Annually
ATM’s – Complete only if account has ATMs
55.
□ □
Does the applicant have a ATM on the premise?
56.
Where is the ATM located? □ Inside □ Outside (If outside, is there adequate lighting?) □ Yes □ No
57.
□ □
Does the insured own/lease the machine?
If yes, who is responsible for placing cash in the machine? __________________________________________
58.
□ □
If the owner of the business is responsible for placement of cash in the machine, how much cash is placed
in the machine? $__________
MI 16 001 07 28
Drivers Information – Only needed for accounts with owned auto’s or repair/service exposure
List Owners and Employees Date of Birth License Number and State Duties
Attach Employee Information Form if additional information is needed.
Any person who knowingly and with the intent to defraud any company or other person les an application for insurance
containing any false information, or conceals for the purpose of misleading, information concerning any fact material thereto,
commits a fraudulent insurance act, which is a crime.
Cooking – Complete only if cooking or deli operation exists
Yes No Question
59.
□ □
Is there a restaurant or other cooking exposure on the premise?
60.
□ □ Type of Cooking (check all that apply): □ Open Flame □ Deep Fat Frying □ Deli Pizza □ Ovens
61.
□ □
A. Provide date of last service to ansul re suppression system. MONTH/YEAR __________/__________
B. Does insured have a service maintenance contract in place to have vent-a-hood system cleaned by
outside contractor every 6 months? IF NO, DECLINE.
62.
□ □
Is the building equipped with a fully operational sprinkler system?
MI 16 001 07 28
The undersigned declares that to the best of his or her knowledge and belief the statements and representations made herein and in any
attachments appended hereto and/or incorporated herein by reference are true and complete and that no material facts have been misstated,
misrepresented, suppressed or concealed. The signing of this application does not bind the undersigned to purchase insurance, nor does review
of the application bind any insurer to issue a policy. It is agreed, however, that this application shall be the basis of the contract should a policy
be issued. If there is any material change in the answers to the questions provided herein or in any of the attachments appended hereto and/or
incorporated herein by reference prior to the effective date of the insurance policy, the applicant must immediately notify the insurer in writing
and the insurer reserves the right in such instance to modify or withdraw any quotation or binder that may have been issued. The undersigned
also represents and warrants that he or she is authorized on behalf of the applicant to complete and sign this application on its behalf.
Applicant Name (Printed) Applicant Title
Applicant Signature* Date
*Electronic Signature and Acceptance □
Producer Information:
Producer Name (Printed) Producer Signature*
Agency Name Date License Number
*Electronic Signature and Acceptance □
* You can apply your signature to this form electronically by checking the Electronic Signature And Acceptance box below your signature line
and by then either applying your electronic signature to this form or by typing your name above your signature line on this form. By doing
so, you hereby consent and agree that your use of a key pad, mouse, keyboard or other device to accomplish the foregoing constitutes your
signature, acceptance, and agreement as if actually signed by you in writing and has the same force and effect as a signature afxed by hand.
Further, you agree that the lack of a certication authority or other third party verication will not in any way affect the validity or enforceability of
your signature or any resulting contract.
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 COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME
AND SUBJECTS THAT PERSON TO CRIMINAL AND CIVIL PENALTIES. (Not applicable in AL, AR, CO, DC, FL, KS, KY, LA, MD, ME, NJ, NM, NY,
OH, OK, OR, RI, TN, VA, VT, WA or WV - see Additional Fraud Notices attached hereto for these States).
MI 16 001 07 28
ADDITIONAL FRAUD NOTICES
NOTICE TO ALABAMA, ARKANSAS, LOUISIANA, NEW MEXICO, RHODE ISLAND AND WEST VIRGINIA APPLICANTS: Any person who
knowingly presents a false or fraudulent claim for payment of a loss or benet or knowingly presents false information in an application for
insurance is guilty of a crime and may be subject to nes and connement in prison.
NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance
company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, nes, denial of insurance
and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts
or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard
to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of
Regulatory Agencies.
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING: It is a crime to provide false or misleading information to an insurer for the
purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or nes. In addition, an insurer may deny insurance
benets if false information materially related to a claim was provided by the applicant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any insurer les a statement of
claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
NOTICE TO KANSAS APPLICANTS: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with
knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part
of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for
payment or other benet pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially
false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material
thereto commits a fraudulent insurance act.
NOTICE TO KENTUCKY APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person les an
application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact
material thereto commits a fraudulent insurance act, which is a crime.
NOTICE TO MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for
the purpose of defrauding the company. Penalties may include imprisonment, nes or denial of insurance benets.
NOTICE TO MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or
benet or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to nes and
connement in prison.
NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy
is subject to criminal and civil penalties.
NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person les
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, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty
not to exceed ve thousand dollars and the stated value of the claim for each such violation.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an
application or les a claim containing a false or deceptive statement is guilty of insurance fraud.
NOTICE TO OKLAHOMA APPLICANTS: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes
any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
NOTICE TO OREGON APPLICANTS: Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by
submitting an application containing a false statement as to any material fact may be violating state law.
NOTICE TO TENNESSEE, VIRGINIA AND WASHINGTON APPLICANTS: 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, nes, and denial of insurance
benets.
NOTICE TO VERMONT APPLICANTS: Any person who knowingly presents a false statement in an application for insurance may be guilty of a
criminal offense and subject to penalties under state law.
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New Renewal Rewrite Service Station Questionnaire (Crum & Forster Insurance)

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Completed 13 July 2021

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