GARAGE QUICK QUOTE

GARAGE QUICK QUOTE
Date Needed:

MonthDayYear
Date
Are you an Insurance Agent?

YesNo
Agency Contact:
Agency Name:
Email:
Phone:
Please enter a valid phone number.
Insured Name:
Entity:

CorporationLLCPartnership
Address

Street

CityState / Province

Postal / Zip Code
New in Business?

YesNo
Do yuo act as a Car Dealer?

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.
Has insured been cancelled or non-renewed?

YesNo
If Yes, why?

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

	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

	1	2	3	4	5	6
1
2
3
4

Radius

3005001000
No. of Dealer tags
Repairs?

YesNo
Body Work?

YesNo
Business Description:
Do they rebuilt wrecks?

YesNo
Do they do repo work?

YesNo
Salvage title sales?

YesNo
Unaccompanied test drives?

YesNo
Tire sales/Service % : New: % Used: %
Non-family contract drives?

YesNo
Liability limits: UM
Med Pay : PIP
Dealer's Physical Damage Comprehensive/ Collision: Deductible:
MPVL:
Is lot fenced?

YesNo
If YES, describe:
Garagekeepers Legal Limits: Deductible:
Comprehensive/Collision MPVL:

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

Should be Empty: