Copyright, 2021 Selective Insurance Company of America. All rights reserved. MW 1006 06 21 Page 1 of 7 WHOLESALERS QUESTIONNAIRE Complete, answer, or check () for “Yes,” where appropriate. ACCOUNT INFORMATION Business Name: Business description: Website(s): Email Address: Year business started: Years of management experience in this business: Describe operations or product lines started in last 3 years: Describe discontinued operations or products: Have you filed for bankruptcy within the past 5 years? Yes No PROPERTY & PROTECTION Hours of operation: Was the building built for your occupancy? Yes No How long at location? Does the property have full sprinkler protection? Yes No If No, provide % covered and describe areas not protected and the square footage: If Yes, answer the following: Is the sprinkler system hooked to a central station? Yes No Is there an ESFR sprinkler system? Yes No Are there in-rack sprinklers? Yes No Is there a fire or booster pump for sprinklers? Yes No Do you have a sprinkler maintenance contract? Yes No Date of last service: Does your business have: 1. Freezers? Yes No If Yes: Are freezers fully sprinklered inside? Yes No Is a program in place to prevent ice plugs in sprinkler piping? Yes No 2. Refrigerators? Yes No If Yes: Refrigerator area: square feet Are units fully sprinklered inside? Yes No Is the building fully protected with central station smoke or heat detection? Yes No If partial, describe areas covered: Is there a central station burglar alarm? Yes No
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Copyright, 2021 Selective Insurance Company of America. All rights reserved. MW 1006 06 21 Page 1 of 7
WHOLESALERS QUESTIONNAIRE Complete, answer, or check () for “Yes,” where appropriate.
ACCOUNT INFORMATION Business Name:
Business description:
Website(s): Email Address:
Year business started: Years of management experience in this business:
Describe operations or product lines started in last 3 years:
Describe discontinued operations or products:
Have you filed for bankruptcy within the past 5 years? Yes No
PROPERTY & PROTECTION Hours of operation:
Was the building built for your occupancy? Yes No How long at location?
Does the property have full sprinkler protection? Yes No
If No, provide % covered and describe areas not protected and the square footage:
If Yes, answer the following:
Is the sprinkler system hooked to a central station? Yes No
Is there an ESFR sprinkler system? Yes No
Are there in-rack sprinklers? Yes No
Is there a fire or booster pump for sprinklers? Yes No
Do you have a sprinkler maintenance contract? Yes No Date of last service:
Does your business have:
1. Freezers? Yes No If Yes:
Are freezers fully sprinklered inside? Yes NoIs a program in place to prevent ice plugs in sprinkler piping? Yes No
2. Refrigerators? Yes No If Yes:
Refrigerator area: square feet
Are units fully sprinklered inside? Yes No
Is the building fully protected with central station smoke or heat detection? Yes No
If partial, describe areas covered:
Is there a central station burglar alarm? Yes No
Copyright, 2021 Selective Insurance Company of America. All rights reserved. MW 1006 06 21 Page 2 of 7
Are there any flammable or combustible liquids stored? Yes No
If Yes describe what and how much:
Are there aerosol can products stored? Yes No
If Yes, what is the quantity and is there any special storage arrangement:
What is the height of warehouse storage? ft Describe the storage arrangement:
CONTINGENCY PLANS Do you have a formal business interruption contingency plan? Yes No
For accounts with refrigerators or freezers: If None, skip to the next section. Are there low temperature alarms? Yes No
Are there back-up generators on-site? Yes No N/A
If Yes, answer the following:
Do they cover all freezers and refrigerators? Yes No
Fuel used:
How often are they tested?
Are there signed contracts with a generator rental company in the event of a power failure? Yes No N/A
Can reefer vehicles in fleet be used to back up storage unit in a power failure? Yes No N/A
GENERAL LIABILITY Any Retail Sales? Yes No If Yes, what are the total retail sales from your locations?
Any Premises outside U.S. operated by you? Yes No Describe:
Any installation, service or repair operations? Yes No Describe:
Any work subcontracted to others? Yes No Amount: $ Describe:
PRODUCTS: Total Gross Sales: $ Internet Receipts: $ International Receipts: $
Receipts breakdown (describe type goods and sales for each category of sales): Durable Goods (Ex: Hardware, Machinery) Non-durable Goods (Ex: Foods, Paper products)
Goods: $ Goods: $
Goods: $ Goods: $
Goods: $ Goods: $
Goods: $ Goods: $
Goods: $ Goods: $
Goods: $ Goods: $
Copyright, 2021 Selective Insurance Company of America. All rights reserved. MW 1006 06 21 Page 3 of 7
Do you import any goods directly? Yes No If Yes, what are receipts? $
Describe:
Are any goods sold under your business label? Yes No If Yes, Describe:
If Yes, describe who designed or developed the product specifications, and who manufacturers:
Are goods of others modified or repackaged by your business? Yes No If Yes, describe:
Do you own any patents or product trademarks? Yes No If Yes, describe:
Do your suppliers provide you with any contractual indemnification or vendor’s coverage? Yes No
If Yes, describe:
Any new product lines planned? Yes No If Yes, describe:
LIQUOR LIABILITY (Beverage Distributors Only) Liquor Liability coverage requested? Yes No ABC License No. Type of License held: (wholesale, retail, etc.) License ever: Revoked Rejected Please provide details:
Are draft trucks rented? Yes No If Yes, How many? Receipts: $
(Attach copy of agreement) If above is Yes, who provides servers?
QUALITY CONTROLS How long are records kept on product sales? years
Are all product batches traceable? Yes No
Are rejected products destroyed? Yes No If No, describe:
Is the “sold by/use by” date on products adhered to? Yes No N/A If No, describe:
Any products recalled in last 10 years? Yes No If Yes, describe each event:
For any machinery modified or re-built:
Are photos or videos taken to confirm the existence of machine guards? Yes No N/A
Are warning labels in place? Yes No N/A
Are the photos or videos retained as a permanent part of the file for the machine? Yes No N/A Is there a formal program for product recalls? Yes No
Copyright, 2021 Selective Insurance Company of America. All rights reserved. MW 1006 06 21 Page 4 of 7
Has your business ever been shut down by a governmental authority? Yes No If Yes, describe:
Has your business ever fined or penalized by a governmental authority? Yes No If Yes, describe:
AUTOMOBILE Drivers
Total number of Drivers that are: Employees: Owner/Operators: Leased:
Temporary:
How many of each have been hired in the last 12 months? Employees: Owner/Operators:
Leased: Temporary:
Hiring practices include: Check all that apply:
Written applications Pre-hire Physical Drug Testing
Pre-Hire MVR Reference Checks Written MVR Criteria
Interview Driving Test Written Test
New hire orientation training includes: Check all that apply:
Do you have an accident investigation program with follow-up? Yes No If Yes, please describe:
Do you use SafetyFirst or any other 1-800 How’s My Driving service? Yes No
Do you use GPS/vehicle tracking or other technology to monitor driver behavior and help identify training needs?
Yes No If Yes, please describe:
Additional Information Required Please attach the following additional information:
• Complete list of vehicle operators (employees, owner/operators and long term leased) including driver’slicense numbers, dates of birth, and year hired.
• Copies of all types of owner/operator agreements/contracts you use.• 4 years of currently valued loss runs from the prior carrier.• IFTAs for the last 4 quarters if applicable.
EEO & EO PRACTICES/PROCEEDINGS
1. Do you have non-discriminatory hiring practices that prohibit exclusion based on race,color, religion, sex, sexual orientation, national origin, disability, or age? Yes No
2. If a membership organization, do you have a non-discriminatory membership policythat prohibits exclusion based on race, color, religion, sex, sexual orientation, nationalorigin, disability, or age? Yes No
3. Has the company been involved in or experienced during the past three years, or arethere now pending, any proceedings before:
a. The Equal Employment Opportunity Commission Yes Nob. The State Human Rights Commission/Department Yes Noc. The State Ethics Commission; or Yes Nod. Similar administrative, regulatory; compliance-office? Yes No
If ‘Yes’ to any of the above please provide detail.
Copyright, 2021 Selective Insurance Company of America. All rights reserved. MW 1006 06 21 Page 7 of 7
4. Has any adverse judgment or settlement been brought against the insured organization whereby part of the settlement included employee and/or management sensitivity training, diversity training, sexual harassment training and/or discrimination training in the past three years? Yes No
If ‘Yes’ to the above please provide detail.
5. Do you allow employees to carry weapons on premises or the jobsite? Yes No