Name
*
First Name
Last Name
Business Name
*
Entity Type
*
S-corp, LLC, LP, C-Corp, Corporation
What is your FEIN?
*
When was the business established?
*
/
Month
/
Day
Year
Date
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?
*
Yes
No
Business Physical Address (if multiple locations, list addresses in property value section at the end)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address if different than above
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Desired Coverage Start Date
*
-
Month
-
Day
Year
Date
What is your estimated annual gross revenue by location and service offerings?
*
Location 1
What is your estimated annual gross revenue by location and service offerings?
Location 2
What is your estimated annual gross revenue by location and service offerings?
Location 3
What is your estimated annual gross revenue by location and service offerings?
Location 4
Number of full-time & part-time employees by location
*
Location 1
Number of full-time & part-time employees by location
Location 2
Number of full-time & part-time employees by location
Location 3
Number of full-time & part-time employees by location
Location 4
What is your estimated annual payroll NOT including owners?
*
Owner payroll
*
Type of coverages requested
*
General Liability
Commercial Property
Workers' Comp
Equipment Breakdown
Business Interruption
Commercial Auto (if mobile, offering valet, or courtesy vehicles)
Cyber Liability
Environmental/Pollution Liability
Any claims in the last 5 years?
*
Please Select
yes
no
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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of
Please upload current 5 year loss runs.
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of
Do you currently have personal lines insurance with Farmers?
*
Please Select
yes
no
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.
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