GARAGE QUICK QUOTE

GARAGE QUICK QUOTE
Date Needed:

MonthDayYear
Date
YesNo
Agency Contact:
Agency Name:
Email:
Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Insured Name:
CorporationLLCPartnership
Address

Street

CityState / Province

Postal / Zip Code
YesNo
YesNo
Retail: % Wholesale %
Broker: % Gross Receipts Repairs:
Prior Carrier (3 years if possible): 1. 2.
3.
Losses in the past 3 years: 1. 2.
3.
YesNo
If Yes, why?

EMPLOYEE INFORMATION All Owners/Officers/employees/family members(NOTE: Out of State licenses must be approved

Rows	NAME	AGE	LICENSE #	MVR VIOLATIONS	FURNISHED Y/N	JOB DUTY
1
2
3
4
5

PLEASE COMPLETE THE PERCENTAGE OF YOUR SALES AND/OR REPAIR OPERATION FOR THE FOLLOWING

Rows	1	2	3	4	5	6
1
2
3
4

3005001000
No. of Dealer tags
YesNo
YesNo
Business Description:
YesNo
YesNo
YesNo
YesNo
Tire sales/Service % : New: % Used: %
YesNo
Liability limits: UM
Med Pay : PIP
Dealer's Physical Damage Comprehensive/ Collision: Deductible:
MPVL:
YesNo
If YES, describe:
Garagekeepers Legal Limits: Deductible:
Comprehensive/Collision MPVL:

Rows	VEHICLE YEAR, MAKE & MODEL	RADIUS	GVW	STATED VALUE	VIT LIMIT	DEDUCTIBLE
1
2
3

Should be Empty: