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3 3 3 K 6 6 6 6 ^ ^ ^ d ^ ^ ^ ^ ^ ^ J J J J J J nK 60 Cutter Mill Road ( Suite 414
Great Neck, NY 11021
516-466-4200 ( HYPERLINK "http://www.butwin.com/"www.butwin.com
fax 516-466-4213 no cover page needed
or exit, save and e-mail HYPERLINK "mailto:allstate@butwin.com" allstate@butwin.com
AUTO REPAIR/ AUTO BODY SHOP SUPPLEMENTAL APPLICATION
These supplemental questions are in addition to a HYPERLINK "http://www.butwin.com/allstate/forms/BOP.doc" \t "_blank" completed BOP application
Applicants Name: FORMTEXT
A g e n t : F O R M T E X T A g e n t P h o n e # F O R M T E X T
M a x i m u m v a l u e p e r c u s t o m e r s ' c a r
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2 4 - h o u r o p e r a t i o n ?
F O R M C H E C K B O X Y es FORMCHECKBOX No
Do we directly perform Towing & Roadside assistance?
FORMCHECKBOX Yes FORMCHECKBOX No
Gasoline sales?
FORMCHECKBOX Yes FORMCHECKBOX No
More than 25% of receipts from Tire Sales?
FORMCHECKBOX Yes FORMCHECKBOX No
More than 15% of receipts from Convenience Store sales?
FORMCHECKBOX Yes FORMCHECKBOX No
Boat work?
FORMCHECKBOX Yes FORMCHECKBOX No
Own dealer plates?
FORMCHECKBOX Yes FORMCHECKBOX No
Emergency vehicle repair?
FORMCHECKBOX Yes FORMCHECKBOX No
Sell / rent / lease / loan vehicles, trailers, or tools to others?
FORMCHECKBOX Yes FORMCHECKBOX No
Perform tire retreading?
FORMCHECKBOX Yes FORMCHECKBOX No
Install trailer hitches?
FORMCHECKBOX Yes FORMCHECKBOX No
Work on race cars?
FORMCHECKBOX Yes FORMCHECKBOX No
Sponsor racing teams?
FORMCHECKBOX Yes FORMCHECKBOX No
Self service bay rentals offered?
FORMCHECKBOX Y e s F O R M C H E C K B O X N o
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F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o
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Guard dog on premises?
FORMCHECKBOX Yes FORMCHECKBOX No
Customers allowed in the shop area at any time?
FORMCHECKBOX Yes FORMCHECKBOX No
Work performed on any vehicles over 20,000 pounds gross vehicle weight?
FORMCHECKBOX Yes FORMCHECKBOX No
Is there at least 1 ASE mechanic are on duty at all times?
FORMCHECKBOX Yes FORMCHECKBOX No
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