SPECIALTY VEHICLE SUPPLEMENT
Top Notch wrecker and roadside
Applicant Name:_______________________________________________________ Operations: Dealer Non-Dealer
AUTOS HEAVY VEHICLES
Autos (private passenger and light trucks) ____%
0 Bucket & Boom Trucks / Cherry Pickers ____%
5
Emergency Vehicles – Police Cars, Ambulances ____%
0 Buses – Passenger Capacity REQUIRED ______ 0
____%
Food Trucks 0
____% Cranes 0
____%
Golf Carts - Licensed for Road Use 0
____% Dump Trucks 20
____%
Military Vehicles 0
____% Emergency Vehicles - Trucks 1
____%
Mopeds / Scooters (must be street legal) 0
____% Logging Trucks / Equipment 10
____%
Motorcycles ____%
0 Refrigerated Vans / Trailers ____%
10
Municipal Vehicles 0
____% Tankers / Tanker Trailers ____%
0
Recreational Vehicles / Motor Homes 10
____% Truck - Heavy & Extra Heavy 44
____%
BOATS & WATERCRAFT OFF ROAD VEHICLES
Boat / Watercraft ____%
0 ATV’s (3 wheeler, 4 wheeler) 0
____%
Jet Ski ____%
0 Dirt Bikes / Motocross Cycles ____%
0
EQUIPMENT Golf Carts - Not Licensed for Road Use 0
____%
Construction / Contractors Equipment ____%
0 Off Road - 4 x 4 0
____%
Farm Equipment & Implements 0
____% Snowmobile 0
____%
Forklifts 0
____% TRAILERS
Lawn / Tree Service Equipment 0
____% Travel Trailers / Campers (pull-behind) ____%
0
OTHER Utility / Service (2,000 lb. capacity) 0
____%
___________________________________________ ____% Trailers – Semi / Livestock 0
____%
1) BREAKDOWN OF WORK PERFORMED - COMPLETE ALL 3 CATEGORIES AS APPLICABLE TO TOTAL 100%
Body and / or Paint 0
______% Radiator 5
______%
Blade Sharpening 0
______% Refrigeration Unit 5
______%
Brakes ______%
5 Roll Bars / Cages ______%
0
Engine Overhaul 20
______% Snow Plow Installation 0
______%
FMCSA Inspections (Answer #6) 2
______% Suspension / Frame 5
______%
Fifth Wheel installation, service or repair 0
______% Tank Cleaning – Internal 0
______%
Hydraulics – General ______%
3 Tank Repair – External ______%
0
Hydraulics – Lifting Apparatus 0
______% Tire Repair or Replacement 5
______%
Oil & Lube 5
______% Tune Up 20
______%
Power Train 20
______% Wash & Detail 0
______%
Other ______%
0 Describe: ______________________________________________
Fabrication and/or parts manufacturing 0
______% Describe: ______________________________________________
Storage or parking space rental 5
______% Receipts: ______________________________________________
Structural Alterations ______%
0 Describe: ______________________________________________
Welding 0
______% Describe: ______________________________________________
EMERGENCY VEHICLES – complete above and:
Aerial Ladder Service 0
______% Lights, Sirens & Radios 0
______%
Ground Ladder Service 0
______% Pump Service 0
______%
Ladder & Hoses ______%
0 Pump Testing 0
______%
MOTORCYCLES – complete above and:
Custom Motorcycle Manufacturing 0
______%
Custom Motorcycle Building 0
______% (assembly, no fabrication)
Trike Conversion 0
______%
MSA020 (04/19)
2) OPERATIONS:
BOATS & WATERCRAFT:
Do you conduct any operations at a marina, or while any watercraft is in the water? Yes ✔ No
Do you make any repairs using fiberglass? Yes ✔ No
If yes, explain where resins are stored on site: ___________________________________________________
EMERGENCY VEHICLE OPERATIONS:
Qualifications and Training: _____________________________________________________________________
Are your mechanics EVT Certified? Yes ✔ No
Do you Install, sell or service medical equipment for ambulances or paramedic’s vehicles? Yes ✔ No
MOTORCYCLE and OFF-ROAD VEHICLE OPERATIONS:
Do you permit off-premises test drives of motorcycles or any off-road vehicles? Yes ✔ No
If yes: Do you have a specific route? Yes ✔ No
Do you accompany using an owned vehicle? Yes ✔ No
Where do you go? ______________________________________
How far do you go? _____________________________________
Are test drives all right turns? Yes No
Do you require helmets, proper clothing and footwear for a test drive? Yes No
Is anyone furnished with personal use of a Motorcycle or other off road vehicle? Yes No
Do you sell any vehicles that are not manufactured in the U.S.? Yes No
If yes, do you obtain them from a U.S. distributor? Yes No
RV, MOTORHOME & CAMPER OPERATIONS
Do you repair kitchen appliances, electrical wiring, or heating/cooling systems? Yes ✔ No
If yes, what percentage of your operation? _______ %
3) Where do you conduct operations?
90
Your Premises ______% 0
Customer’s Location ______% 10
Roadside ______%
4) Do you take autos to Trade Shows, Fairs or Special Events? Yes ✔ No
If yes, where do you go / how many per year? ____________________/_______
5) Are your mechanics ASE Certified? ✔ Yes No
1-3
If no, how many years of related experience do you require? __________________
6) Do you test drive any vehicles over 26,000 off-premises? ✔ Yes No
If yes, do your drivers possess CDL licenses? ✔ Yes No
7) If you do FMCSA annual vehicle safety inspections, does / has the Inspector:
a. Understand the FMCSA inspection criteria? ✔ Yes No
b. Mastered the inspection methods, procedures, tools and equipment? ✔ Yes No
c. Successfully completed a State or Federal inspection training program? ✔ Yes No
d. Have at least 1 year of training and/or experience consisting of:
• Participation in a manufacturer sponsored training program; or
• Experience as a mechanic or inspector:
o In a motor carrier maintenance program; or
o In a commercial garage; or
o For a State or Federal Government? Yes ✔ No
Additional Information: _________________________________________________________________________________________
This questionnaire does not bind the Application nor the Company to complete the insurance, but it is agreed that the information contained
herein shall be part of the basis of the contract should a policy be issued. By signing you are hereby certifying that all information is
accurate to the best of your knowledge.
_______________________________ 3/15/23
_____________/__________________________________________
Signature of Agent Date Signature of Applicant
MSA020 (04/19)
