ROADSIDE ASSISTANCE EVALUATION FORM

Enter your details

Please complete the sections relevant to your type of business in the form below and click on submit.

1. How long has the business been in operation?

  0 to 1 years
  1 to 2 years
  2 to 3 years
  3 to 4 years
  more than 4 years

2. How does the business operate?

Business Hours only
24 Hours

3. Do you have full and comprehensive professional indemnity insurance?

Yes
No

If Yes, name of insurer

and policy number

4. Have you been approved by an Insurance Company?

Yes No

5. Have you been approved by a Manufacturer?

Yes No

6. Do you belong to a Trade Association?

Yes No

7. Are you VAT registered?

Yes No

8. Please indicate if any of the following the manufacturers and insurance companies have officially approved you as a contractor or service provider, and if you belong to any towing or other association. (if so, you will need to provide us with the name and telephone number of the person in that organization who can verify the approval)

GMSA

Yes No

Mazda

Yes No

Hyundai

Yes No

Toyota

Yes No

BMW

Yes No

Mercedes

Yes No

Audi

Yes No

Ford

Yes No

Nissan

Yes No

Alfa Romeo/Fiat

Yes No

Santam

Yes No

Auto & General

Yes No

Mutual & Federal

Yes No

SA Eagle

Yes No

Outsurance

Yes No

Hollard

Yes No

Regent

Yes No

RMI

Yes No

UTASA

Yes No

Others (Please specify)

For each organisation that you selected "Yes" for above, please provide
the organisation name, contact person's name and telephone number.

eg. GMSA, John Smith, 076-123-4567
Nissan, Nigel Green, 082-123-4567

9. Please indicate number of each type of equipment:

eg. 1

  Rollback
  LDVs
  Sling Tow / Other Partial Lift
  Courtesy Vehicle
  Motorcycle Trailer

10. Are all Vehicles/Drivers equipped with Radio Communication/Cell Phones?

Radios Cell Phones

11. Are any of the vehicles currently in use older than 5 years?

Yes No

12. Do all the above vehicles possess a full service history?

Yes No

13. Are any of your drivers first aid compliant?

Yes No

14. Are you willing to invoice our corporate clients directly ?
(Payments are processed on a 30 day basis)

Yes No

15. Do you have access to / are you prepared to perform the following services?

Spares and appropriate qualifications to assist with minor repairs

Yes No

Locksmith Services

Yes No

Auto Electrical Services

Yes No

Mechanical Services

Yes No

Panel-beating Services

Yes No

Take fuel or diesel out to members?

Yes No

Safe storage facilities

Yes No

Change tyres of members?

Yes No

Assist with starting of the vehicle under safe and appropriate conditions

Yes No

Deliver member's vehicle from your place of business to an address to be provided to you?

Yes No

16. RESPONSE TIMES:

In a Non-built up area (rural) - within a radius of 20 km

0-20 min 21-30 min
31-45 min >45 min

In a Non-built up area (rural) - within a radius of 21-40 km

0-20 min 21-30 min
31-45 min >45 min

In a Non-built up area (rural) - within a radius of 41-50 km

0-30 min 31-40 min
41-50 min >50 min

In a Non-built up area (rural) - within a radius of 51-100 km

0-40 min 41-50 min
51-60 min >60 min

In a built up area - within a radius of 20 km

0-20 min 21-30 min
31-45 min >45 min

In a built up area - within a radius of 21-40 km

0-30 min 31-40 min
41-50 min >50 min

In a built up area - within a radius of 41-50 km

0-40 min 41-50 min
51-60 min >60 min

In a built up area - within a radius of 51-100 km

0-50 min 51-60 min
61-70 min >70 min

17. Which areas (towns and suburbs) are you prepared to service?

18. Please list any areas (such as townships) that you are
specifically NOT prepared to service:

19. Rates:

(All rates to excl VAT)	Normal Hours	After Hours	Sunday Pub Hol
1. Call-out
2. Distance incl. in call-out fee
3. Rate per km thereafter
4. Call-out Rollbacks
5. Rate per km thereafter
6. Minor Roadside call-out
7. Rate per km thereafter
8. Accident Recovery Rate
9. Storage rate per day

20. Other relevant information you would like to add:

Company Name

Your Name

Position in Company

Physical Address

Postal Address

Business Phone

Business Fax

Cell Phone

Please enter this number in the box below