SCWA - Car Wash Quote Request

Name

First NameLast Name
Business Name
Entity Type
S-corp, LLC, LP, C-Corp, Corporation
What is your FEIN?
When was the business established?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Number of Locations
Type of Car Wash
Self-Serve, Full Service, Tunnel, Automatic, Detailing, Mobile, etc.
Description of all business activities:
Details on services you offer (detailing, vacuuming, membership programs, oil changes, etc.)
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Do we have permission to communicate via text with you at this number?
Business Physical Address (if multiple locations, list addresses in property value section at the end)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address if different than above

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Desired Coverage Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Estimated Annual Gross Revenue

Rows	Location 1	Location 2	Location 3	Location 4
Estimated Annual Gross Revenue
Percent of Revenue from Self Service
Percent of Revenue from IBA
Percent of Revenue from Tunnel

Employee Count by Type - this should reflect the average daily staffing levels maintained throughout the year.

Rows	Less than 30 hours per week	More than 30 hours per week
Owners Involved in day-to-day operations
Auto Detailing
Mechanic or Equipment Maintenance
Cashier, Janitorial or clerical only

What is your estimated annual payroll NOT including owners?
Owner payroll
Type of coverages requested
Any claims in the last 5 years?
Hours of operation
List types of premise protection per location (i.e. alarm system, cameras & recording storage, lighting, etc.):
Number of Additional Insureds and COIs
How many lenders, lessors, vendors need to be listed and an estimate of the annual number of COIs requested.
Property value details
Other location addresses; Specific property values for building(s), equipment and inventory/supplies; ownership status of all property (own vs. lease/finance)
Please upload current declaration pages.

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Please upload current 5 year loss runs.

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Do you currently have personal lines insurance with Farmers?
So we can apply this multi-line discount.
Anything else you would like us to know?
Current carrier information; Do you have an alarm and security systems in place?; Details of any water reclamation and drainage measures, employee training and other risk mitigation strategies to secure the best value possible.
Should be Empty: