MANUFACTURED HOME DEALER CHECKLIST
*
Required.
1
*
Name of Dealership:
2
*
Address:
Address Line 2:
3
*
City:
*
State:
*
Zip:
4
*
Phone:
Fax:
5
*
Name of Contact:
6
*
E-Mail:
7
Website:
8
Tax ID#:
9
Years In Business:
10
Current Ownership Dates from:
11
Years. Of Management Experience:
12
Owners and % of ownership? (Officers):
%
On each building we need to know the following:
13
Building 1
Building 2
Building 3
Building 4
Amount?
Contents?
Construction:
Sq. Footage:
Year Built:
# Stories:
Deductibles:
Burglar alarm:
Select
Local
Central Station
Select
Local
Central Station
Select
Local
Central Station
Select
Local
Central Station
Sprinklered?
Select
Yes
No
Select
Yes
No
Select
Yes
No
Select
Yes
No
Fire Extinguishers?
Select
Yes
No
Select
Yes
No
Select
Yes
No
Select
Yes
No
Responding Fire Dept:
If bldg. over 25 yrs old
Year of updates?
Spec Homes?
Select
Yes
No
Select
Yes
No
Select
Yes
No
Select
Yes
No
If any, list locations
Inland Marine:
14
Employee tools:
15
Tools/Equipment:
16
Signs:
17
Dealers Open Lot limit?
18
Deductible?
19
Reporting/non-reporting?
20
Umbrella Limit?
21
Retention Limit?
22
Subcontractors Cost:
23
Carpentry payroll:
Work Comp info:
24
Coverages?
25
Experience Mod/Loss runs?
Select
Yes
No
Employees:
26
Employee 1
Employee 2
Employee 3
Employee 4
Job duties:
payroll:
part-time or full-time:
driving or non-driving:
Drivers:
Date of Birth:
Drivers Licence #:
Social Security #:
27
# of Dealer Plates
28
Number of tow vehicles?
29
Do you haul for others?
Select
Yes
No
30
Any furnished autos?
Select
Yes
No
If yes, to whom?
Current Insurance Companies and renewal dates.
31
Company:
Renewal Date:
32
Dec Pages/Loss runs for 4 years?
33
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