All Risks, Limited – National Specialty Programs
th
10150 York Road, 5 Floor, Hunt Valley, MD 21030
Phone: 800-366-5810
Fax: 410-828-8179
Contact us: [email protected]
Bicycle Manufacturer/Distributor Product Questionnaire
In order to provide a quote, ACORD 125, 126, and 140 must be completed along with the supplemental.
Name of Business: ___________________________________________ Year Business Started: _________
Address: __________________________________________________________________________________________
City/State/Zip _____________________________________________________________________________________
Total Sales:
Contact Person:____________________________________________
This Year:
$ _________
Email Address: ____________________________________________
st
1 Prior Year: $ _________
Phone Number: ___________________________________________
nd
2 Prior Year: $ _________
rd
3 Prior Year: $ _________
OPERATIONS:
Bicycle Manufacturer
Bicycle Component Manufacturing
Bicycle Assembly (components manufactured by others)
Accessory Manufacturer (gloves,
Distributor
clothing, packs, etc.)
1. Describe operations: _________________________________________________________________________
____________________________________________________________________________________________
2. Describe operations not related to the bicycle Industry: ____________________________________________
____________________________________________________________________________________________
3. Do you sponsor any professional racing teams?
Yes
No
If yes, please describe: __________________________________________________________________
_____________________________________________________________________________________
4. Do you sponsor any professional bicycle racing events?
Yes
No
If yes, please describe: __________________________________________________________________
_____________________________________________________________________________________
Please provide: 1. Copies of all current advertising material
2. Copies of all current product brochures
3. Full details on any product claims (all claims open or closed)
Attached
Attached
Attached
To Follow
To Follow
To Follow
5. Describe product quality control program: _________________________________________________________
____________________________________________________________________________________________
6. How are your new product lines tested to comply with Consumer Product Safety Commission (CPSC) bicycle
regulation? ___________________________________________________________________________________
_____________________________________________________________________________________________
7. Do your records enable you to track product runs or sales to the dealer for recall?
Yes
No
If yes, please describe: __________________________________________________________________
Bicycle Manufacturer/Distributor Application – 12.16
Page 1 of 4
Please check below the kinds of operations conducted in your manufacturing facility:
Your Operation
or
Contracted to Others
Assembly
Carbon Fiber Products Manufacturing
Casting of Metal Parts
Electroplating or Anodizing
Fabric Sewing
Heat Curing Oven
Machining Metal
Other Plastic Products Manufacturing
Plastic Products Injection Molding
Polishing and Buffing
Spray Painting
Welding – Steel/Aluminum
Welding – Titanium
Other (List) ___________________________
Other (List) ___________________________
Please describe your manufacturing process: ______________________________________________________
___________________________________________________________________________________________
Do your subcontractors carry insurance coverages or limits less than yours?
Yes
No
If yes, please explain: __________________________________________________________________
LIST OF ALL CURRENT PRODUCTS – Manufactured or Sold
Product Name
Description
Manufactured
Imported (by you)
Wholesaled
Manufactured
Imported (by you)
Wholesaled
Manufactured
Imported (by you)
Wholesaled
Volume
$ ________ Sales
$ ________ Units
$ _______ Sales
$ _______ Units
$ _______ Sales
$ _______ Units
List and describe additional products to be released in the next two years: ______________________________
___________________________________________________________________________________________
List and describe any discontinued products that are not related to the bicycle industry: ____________________
____________________________________________________________________________________________
Do you sell your product in foreign countries?
If yes, what percentage of your total receipts is from foreign sales? ________ %
If your product is manufactured in a foreign country, does the foreign manufacturer have
insurance that will respond in the United States?
Bicycle Manufacturer/Distributor Application – 12.16
Yes
No
Yes
No
Page 2 of 4
PROPERTY INFORMATION
(If more than 2 locations, please photocopy the below and complete for additional locations.)
Location #1
Bldg. # __________ Address: _________________________________________________ Zip Code: _________
Protection Class: __________
Inside City Limits?
Yes
No County Name: _______________
Construction:
Frame
Joisted Masonry
Non-Combustible
_________________
Year Built: _______
Miles to Fire Station: _______
Feet to Fire Hydrant: _______
Year of Updates (if over 25 years old): Wiring _______ Heating _______ Plumbing _______ Roof: _______
Total Building Area: _______
Insured’s Area: _______
Please check your current safeguards:
Burglar Alarm
Dead bolt locks on all doors
Bars on all windows
Metal Doors
Bikes locked together when closed
Building
Value
$ __________
Personal Property
$ __________
Business Income
$ __________
Extra Expense
Minicomputer/EDP
(100% coinsurance)
$ __________
$ __________
Coverages and Limits
Coinsurance __________ Deductible __________
Causes of Loss: Basic
Broad
Special
Coinsurance __________ Deductible __________
Causes of Loss: Basic
Broad
Special
_____ % of Coinsurance (50% min) or
Monthly limit:
1/3
1/4
1/6
40%
80%
100%
Hardware: $ __________
Software: $ __________
Extra Expense: $ __________
Location #2
Bldg. # __________ Address: _________________________________________________ Zip Code: _________
Protection Class: __________
Inside City Limits?
Yes
No County Name: _______________
Construction:
Frame
Joisted Masonry
Non-Combustible
_________________
Year Built: _______
Miles to Fire Station: _______
Feet to Fire Hydrant: _______
Year of Updates (if over 25 years old): Wiring _______ Heating _______ Plumbing _______ Roof: _______
Total Building Area: _______
Insured’s Area: _______
Please check your current safeguards:
Burglar Alarm
Dead bolt locks on all doors
Bars on all windows
Metal Doors
Bikes locked together when closed
Building
Value
$ __________
Personal Property
$ __________
Business Income
$ __________
Extra Expense
Minicomputer/EDP
(100% coinsurance)
$ __________
$ __________
Coverages and Limits
Coinsurance __________ Deductible __________
Causes of Loss: Basic
Broad
Special
Coinsurance __________ Deductible __________
Causes of Loss: Basic
Broad
Special
_____ % of Coinsurance (50% min) or
Monthly limit:
1/6
1/3
1/4
40%
80%
100%
Hardware: $ __________
Software: $ __________
Extra Expense: $ __________
Bicycle Manufacturer/Distributor Application – 12.16
Page 3 of 4
REQUEST FOR FINANCIAL INFORMATION
Explanation and Instructions: Information concerning the financial condition of an insured location is essential to
underwriters. Judgements regarding both eligibility and premium level are made partially based on financial
condition. Information submitted will be kept strictly confidential.
Part I examines your trend in revenues and expenses.
Part II examines solvency by comparing your current assets to your current liabilities.
Part III examines both short and long-term debt.
Part IV refers to your credit history.
Complete Financial Statements including Balance Sheet and Income Statements may be submitted as a
substitute for this financial request.
PART I
LAST 12 MONTHS ENDING ______________________
Gross Revenue
Cost of Goods (not labor)
Gross Profit
Cost of Labor
Overhead Expenses
Profit <Loss> after Expenses
______________________
______________________
______________________
______________________
______________________
______________________
PART II
Cash (on hand or in banks)
Marketable Securities
Accounts Receivable
Inventory
TOTAL OF ABOVE
_______________
_______________
_______________
_______________
_______________
PART III
List any Loans, Mortgages or any other Contract Debt
To Whom
Amount Maturity Monthly
Date
Payments
Payable to Vendors
Taxes Payable (not F.I.T)
Income Taxes Payable
Other Current Payables
TOTAL OF ABOVE
_______________
_______________
_______________
_______________
_______________
PART IV
Are you currently past due on
payroll, sales or other taxes?
Yes
No
Are you currently undergoing any
form of bankruptcy?
Yes
No
Who prepares your financial statements and/or tax
returns? ___________________________________
QUESTIONNAIRE MUST BE COMPLETED FOR INSURANCE QUOTE
Questionnaire Completed By:
Name: ______________________________________
Title: __________________________________
Signature: ___________________________________
Date: __________________________________
Bicycle Manufacturer/Distributor Application – 12.16
Page 4 of 4