Garage Application

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Garage Application

All Questions must be answered in full, signed and dated by the Applicant

Garage Application

Broker#:
Broker:
Broker Location:
Retailer:
Retailer Location:
Phone#
Applicant Name
Mailing Address
Proposed Policy Period
Location #1
Location #2
Entity Individual Partnership Joint Venture Corporation Other
Insured's Website Address
Inspection and Audit Contract/Phone Number
Years in business
Years of experience in this field
Nature Of Business
Dealer: Franchised Non-Franchised
Please Indicate Percent:
Consigned Autos Held for Sale
Auto Auctions
Other:
Owned Autos Held for Sale
Wholesale Autos
Non-Dealer: Repair Shop Gas Station Parking Facility Other
UNDERWRITING INFORMATION
1. Do you engage in any other operations? Yes No
2. Do you sponsor sporting or social events? Yes No
3. Do you sponsor or own any Race cars? Yes No
5. Do you structurally alter or convert vehicles from their original design? Yes No
6. Do you repossess vehicles for others? Yes No
7. Do you engage in fuel conversion? Yes No
8. Do You Engage in auto pawning? Yes No
9. Do You Allow customers in the work area? Yes No
10. Do you own or operate a car crusher or stack salvaged autos more than two high? Yes No
EXPLAIN ALL YES RESPONSES
PLEASE INDICATE PERCENTAGE OF THE FOLLOWING TYPE OF AUTOS YOU ARE INVOLVED IN
Private Passenger Type Including Light & Medium Trucks - New Sales %:
Private Passenger Type Including Light & Medium Trucks - New Repair %:
Private Passenger Type Including Light & Medium Trucks - Used Sales %
Private Passenger Type Including Light & Medium Trucks - Used Repair %
Antique/Classic Cars Sales %
Antique/Classic Cars Repair %
Boats - Other Than Jet Skis Sales %
Boats - Other Than Jet Skis Repair %
Jet Skis Sales %
Jet Skis Repair %
Buses Sales %
Buses Repair %
Contractors Equipment **incude complete list** Sales %
Contractors Equipment **include complete list** Repair %
Farm Equipment Sales %
Farm Equipment Repair %
Emergency or Public Livery Sales %
Emergency or Public Livery Repair %
Heavy Truck (over 26,000 GVW) **supplement required** Sales %
Heavy Truck (over 26,000 GVW) **supplement required** Repair %
Kit Cars or Other Auto Manufacturing Sales %
Kit Cars or Other Auto Manufacturing Repair %
Motorcyles, ATVs, Scooters, Snowmobiles **supplement required** Sales %
Motorcyles, ATVs, Scooters, Snowmobiles **supplement required** Repair %
Mobile Homes Sales %
Mobile Home Repair %
Recreational Vehicles and Campers **supplement required** Sales %
Recreational Vehicles and Campers **supplement required** Repair %
Semi Trailers Sales %
Semi Trailers Repair %
Trailers - Other than Semi Trailers Sales %
Trailers - Other than Semi Trailers Repair %
NON-DEALERS OPERATIONS
Alarm, Stereo or Navigational System %
Auto Dismantling %
Auto Maintenance or Repair Including Bedliner %
Auto Painting with UL approved spray booth %
Auto Painting without UL approved spray booth %
Auto Parts (uninstalled) Receipts %
Body Shop %
Butane, Propane or other Liquefied Gas Sales %
Car Wash - Full Service %
Convenience Store Receipts %
Detailing %
Driveaway Contracor or Wrecker Service %
Frame or Unibody Straightening %
Gasoline Station - Full Service %
Gasoline Station - Self Service %
Impound Yards %
Mobile Auto Repair %
Oil/Lube Service %
Parking Lots & Garages (self park) %
Tire Dealers - New %
Tire Dealers - Used, Retreads or Split Rims %
Trailer Hitch Installation or Repair %
Upholstery %
Valet Parking **supplement required** %
Van Conversion %
Window Tinting %
Windshield Installation/Repair %
Other:
VEHICLE STORAGE & VALUES
Owned Autos
How are Vehicles Stored? Standard Lot Non Standard Lot Building Unprotected Lot
Maximum value any one Auto?
Maximum number of Autos?
Non-Owned Autos
How are Vehicles Stored? Standard Lot Non-Standard Lot Building Unprotected Lot
Maximum value any one Auto?
Maximum number of Autos?
*Standard Lot: Standard open lots are open parking storage lots enclosed on all sides by a metal cyclone or equivalent fence not less than six ft. in height
or bounded on one or more sides by the wall or walls of a building; with no protected openings, and with the exposed sides of the lot enclosed by a meal cyclone or equivalent fence not less than six feet in height,
with openings securely locked when unattended. Non-standard Lot: Any other type of protection or fencing. Unprotected Lots: All Other
EMPLOYEE AND NON-EMPLOYEE INFORMATION
YOU MUST COMPLETE THE FOLLOWING INFORMATION FOR ALL EMPLOYEES, DRIVERS AND HOUSEHOLD MEMBERS
Employee 1 Name:
Employee 1 Driver's License #:
Employee 1 Driver's License State:
Employee 1 Date of Birth:
Employee 1 Violations & Accidents, Prior 3 Yrs:
Emloyee 1 Status:
Employee 1 Hours Worked:
Employee 1 Auto Use:
Employee 2 Name:
Employee 2 Driver's License #:
Employee 2 Driver's License State:
Employee 2 Date of Birth:
Employee 2 Violations & Accidents, Prior 3 Yrs:
Employee 2 Status:
Employee 2 Hours Worked:
Employee 2 Auto Use:
Employee 3 Name
Employee 3 Driver's License #:
Employee 3 Driver's License State:
Employee 3 Date of Birth:
Employee 3 Violations & Accidents, Prior 3 Yrs:
Employee 3 Status:
Employee 3 Hours Worked:
Employee 3 Auto Use:
Employee 4 Name:
Employee 4 Driver's License #:
Employee 4 Driver's License State:
Employee 4 Date of Birth:
Employee 4 Violations & Accidents, Prior 3 Yrs:
Employee 4 Status:
Employee 4 Hours Worked:
Employee 4 Auto Use:
Employee 5 Name:
Employee 5 Driver's License #:
Employee 5 Driver's License State:
Employee 5 Date of Birth:
Employee 5 Violations & Accidents, Prior 3 Yrs:
Employee 5 Status:
Employee 5 Hours Worked:
Employee 5 Auto Use:
STATUS:
1. Active Owner, Partner or Officier
2. Inactive Owner, Partner or Officer
3. Salesperson
4. Lot Person
5. Mechanic
6. Clerical
7. Spouse of Owner, Partner or Officer
8. Children of Owner, Partner or Office
9. Spouse of any other person furnished an auto
10. Children of any other person furnished an auto
11. Occassional or Contract Driver
12. Other
HOURS WORKED
F = Full Time (Over 20 hours per week)
P = Part Time (20 or less hours per week)
N = Non-Employee
AUTO USE:
A = Furnished a covered auto for personal use
B = Uses a covered auto strictly for business use
C = Does not driver a covered auto
THREE-YEAR PRIOR CARRIER LOSS HISTORY
Current Carrier
Policy Period
Policy Premium
Prior Carrier
Policy Period
Policy Premium
Prior Carrier
Policy Period
Policy Premium
Is there Prior Insurance? Yes No
Date of Loss:
Amount Paid/Reserve
Description of loss including driver
Are there Prior Losses? Yes No
COVERAGES & LIMITS
Garage Liability
Limit Of Liability
Auto, Each Accident
Other Than Auto, Each Accident
Other Than Auto, Aggregate Limit
Deductible
BI
PD
Dealers Open Lot Comprehensive Collision False Pretense Specified
Limit of Coverage
Limit Per Location
Limit Per Auto
Deductible
Other Than Collision
Collision
Garage Keepers Legal Liability Direct Excess Direct Primary Comprehensive Specified Collision
Limit of Coverage
Limit Per Location
Limit Per Auto
Deductible
Other Than Collision
Collision
In-Tow Coverage For Hire Not For Hire
Limit Per Tow Truck
# of Tow Trucks:
Medical Payments
Auto
Garage Operations
Broadened Coverage (Includes Personal Injury & $50,000 Fire Legal) Yes No
Fire Legal Liability Yes No
Fire Limit
Personal Injury Liability Yes No
Hired Auto Yes No
Broad Form Products Yes No
Additional Insured Yes No
Waiver of Subrogation Yes No
Name
Address
Insurable Interest
Uninsured Motorists Coverage
Each Accident
Underinsured Motorists Coverage
Each Accident
Number of Dealer Tags:
Personal Injury Protection
Per Statute
Radius of Pickup & Delivery: None 0-300 Miles 301-500 Miles 501-1000 Miles +1000 Miles
Dealer's Errors & Omissions Title E&O Federal Odometer E&O Truth in Lending E&O Insurance Agents E&O
Scheduled Auto Liability or Physical Damage: Complete the Scheduled Auto Supplement
Additional Information
NOTICE: The policy of insurance applied for does not provide coverage as required by EPA 40 CFR Parts
280 and 281 for underground storage tanks nor coverage under CERLA or similar state or federal environmental act(s). THIS POLICY EXCLUDES
email *

09/01/07 ed.