Frame straightening supplemental application

Дата канвертавання24.04.2016
Памер21.33 Kb.


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All questions must be answered in full. Application must be signed and dated by the applicant.

Applicant’s Name      




Applicant Mailing Address      



Applicant’s Phone Number      

Web Address      

Inspection Contact      

Proposed Policy Period       to      

Phone Number for Inspection Contact      

Applicant is  Individual  Partnership  Corporation  Joint Venture  Other      


Location #1      

Location #2      

Location #3      





  1. List Equipment







  1. Which type are you using?

 Bench Type

 Floor Model

 Drive Up System

  1. How many years experience do you have in frame straightening?      

Do You Have

  1. Mechanics with I-CAR training or ASE certification?  Yes  No

  1. Electrical and/or hydraulic pulling equipment?  Yes  No

  1. Current dimensional guides appropriate to the vehicle being repaired?  Yes  No

  1. A four (4) point clamping system to secure the vehicle being repaired?  Yes  No

  1. A gauging system capable of three (3) dimensional measuring?  Yes  No

  1. Appropriate welding equipment that meets or exceeds manufacturer’s requirements and/or a MIG welder?  Yes  No

  1. An UL approved and labeled spray booth complete with air makeup system and a fresh air supply for painters?

 Yes  No

  1. A spray booth that complies with all OSHA regulation?  Yes  No

  1. A paint system that can produce an original equipment manufacturer’s type finish (specifically a base coat and urethane clear coat)?  Yes  No

  1. A lift or drive on frame machine setup capable of lifting vehicles at least three (3) feet off the floor?  Yes  No

  1. A current registration with the EPA?  Yes  No


Explain ALL “Yes” Responses

Do You

  1. Sublease your license or rent space to others?  Yes  No

  1. Repair vehicles with damage totaling more than 60% of the ACV of a vehicle?  Yes  No

  1. Buy salvage for reconstruction?  Yes  No

  1. Subcontract any work to others?  Yes  No

  1. Replace air bags?  Yes  No

If yes,  new or  used?

  1. Has this business operated under any other name?  Yes  No





Notice The policy of insurance applied for does not provide coverage as required by Environmental Protection Agency (EPA) 40 CFR Parts 280 and 281 for underground storage tanks nor any coverage under CERCLA or similar state or federal environmental act(s). THIS POLICY EXCLUDES ALL COVERAGE FOR POLLUTION.

Any person who knowingly and with intent to defraud any insurance company or other person who files 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.

This application shall not be binding unless and until confirmation by the company or its duly appointed representative has been given, and that a policy shall be issued and a payment shall be made, and then only as of the commencement date of said policy and in accordance with all terms thereof. The said applicant hereby makes these covenants and agrees that the foregoing statements and answers are a complete and true statement of all facts and circumstances involving the risk to be insured. The same are hereby considered a representation on the part of the insured, and made as the basis and conditions for which coverage will be granted.

Producer’s Signature Date Applicant's Signature Date


As part of our underwriting procedure, a routine inquiry may be made to obtain applicable information concerning character, general reputation, personal characteristics, and mode of living. Upon written request, additional information as to the nature and scope of the report, if one is made, will be provided.


Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

S320FRs (09/06) Page of

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