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Synergy Coverage Solutions, LLC 217 S. Tryon Street Charlotte, NC 28202 www.synergyinsurance.net
T 704.927.2860 F 704.927.2867 [email protected]
Equipment Dealer Supplemental Application
Name: _________________________________________________________________________________ Website: _______________________________________________________________________________
General information:
1) What type of equipment do you sell and/or service?
2) Do you demonstrate equipment on customers’ premises or at fairs? Yes No
3) Radius of operations: ______________ miles
4) Do you have a roving repair service? Yes No
5) Do you have a delivery service? Yes No
6) Do you mount tires for farm machinery and power equipment? Yes No
a) If yes, describe the training your tire specialists receive:
7) Does your organization do any spray painting? Yes No
a) If yes, do you use a well-ventilated spray booth? Yes No
b) Do all workers in the spray painting areas wear respiratory and eye protection? Yes No
8) Does your organization do any welding? Yes No
a) If yes, what personal protective equipment is used? (indicate with checkmark)
Gloves Other: ________________________________________
Eyes and face protection
Welding shields
9) Are employees required to wear PPE? Yes No
10) How many mechanics do you employ? ______________________________________
a) Have they been trained by factory-sponsored schools? Yes No
11) Are all mechanics currently certified? Yes No
12) Are mechanics recertified annually? Yes No
Synergy Coverage Solutions, LLC 217 S. Tryon Street Charlotte, NC 28202 www.synergyinsurance.net
T 704.927.2860 F 704.927.2867 [email protected]
Hiring Practices
1) Please indicate hiring practices currently in place:
Application
Drug testing
Criminal background check
Pre-employment Medical Questionnaire
Fit for Duty or Pre-Employment Physical
2) What training and supervision do new or temporary workers receive?
Employer Signature: ____________________________________________ Date: _________________
