GARAGE & AUTO DEALER APPLICATION

GARAGE & AUTO DEALER APPLICATION
ALL QUESTION MUST BE ANSWERED IN FULL, SIGNED AND DATED BY THE APPLICANT
Are you filling this out on behalf your client?

YesNo
I am a(n)

Insurance BrokerReal Estate AgentLender / Mortgageother
Name*
Phone*
Email*
Applicant Information
Proposed Effective Date :

MonthDayYear
Date
Name of the Applicant (include DBA)
Applicant is :

IndividualJoint venturepartnershipLLCOther
Mailing Address :

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact:
Phone Number
Please enter a valid phone number.
Website:
Number of years in business:
Number of years in experience in this field:
Description of Operations
Location Address #1

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Location Address #2

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Location Address #3

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

EMPLOYEE AND NON-EMPLOYEE INFORMATION

	Loc. #	Name	Drivers License Number & State	Date of Birth	Violations Or Accidents within the Past 3 years	Job Description or Relationship to insured (see below)	Full Time Or Part Time (see below)	Furnished an Auto for Personal Use ? Yes/No
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10

Have all owners, employees, non-employees, household members, independent contractors who work for the business and drivers who may operate your vehicles or vehicles in your care, on a regular or infrequent basis been disclosed above?

YesNo

INDICATE PERCENTAGE OF THE FOLLOWING TYPE OF AUTOS SOLD / REPAIRED


1
2
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12

UNDERWRITING INFORMATION
How do you transport autos?

Driven by EmployeesDriven by Temporary or Contract DriverOwned Tow Truck Or car HaulerOwned Tow Bar or DollyContracted to a third party tow truck or car Hauler
Towing capacity:
Do You:
Engage in any other operations?

YesNo
Engage in fuel conversion?

YesNo
Engage in performance enhancements?

YesNo
Tow for hire?

YesNo
Repossess vehicles for others?

YesNo
Loan, Lease or Rent autos to others?

YesNo
Engage in auto pawning or auto title loans?

YesNo
Dismantle autos or have salvage operations?

YesNo
Own or operate a car crusher?

YesNo
Stack salvaged autos more than 2 high?

YesNo
Work at airport, seaport or railroad premises?

YesNo
Engage in Breathalyzer / ignition interlock?

YesNo
Manufacture / Fabricate any auto parts?

YesNo
Structurally alter or convert vehicles from their original factory design?

YesNo
EXPLAIN ALL YES RESPONSES :
Do You:
Accompany customers in the service/repair area?

YesNoN/A
Secure all keys in a lock box or a secure cabinet away from vehicle?

YesNo
Obtain certificates of insurance from all sub-contractors?

YesNoN/A
Are all paints and solvents stored in a fire resistive cabinet outside the paint booth?

YesNoN/A
Are all spray painting operations confined to an UL approved booth?

YesNoN/A
If No, is there explosion proof lighting and adequate ventilation?

YesNo
PRIOR INSURANCE COMPANY AND LOSS HISTORY
Current Carrier Policy Period
Policy Premium
Prior Carrier Policy Period
Policy Premium
Prior Carrier Policy Period
Policy Premium
Prior Carrier Policy Period
Policy Premium
Prior Carrier Policy Period
Policy Premium

	Date of Loss	Amount paid / reserve	Description of loss	Driver involved
1
2
3
4

If there is No Prior Insurance, check the box.If there are No Prior Losses, check the box.
Any policy or coverage Declined, Cancelled or Non-Renewed during the prior Three (3) years? (Missouri Applicants - Do not answer this question).

YesNo
If Yes, Explain:
DEALERS OPERATIONS
Retail % Wholesale %
Internet % Auction %
Consigned %
Non - Franchised DealershipNew Auto/ Franchised Dealership
Do you obtain Drivers License and proof of insurance before all test drives?

YesNo
Are all test drivers accompanied by a salesperson?

YesNo
Do you allow extended or overnight test drives?

YesNo
Do you rent or loan dealer plates to others?

YesNo
Do you offer in - house financing or Buy here / Pay Here?

YesNo
If yes, are titles transferred to customer at the beginning of the finance period and your business named as a lienholder?

YesNo
Radius of pickup & delivery

0 - 300 Miles301 - 500 miles501 - 1,000Unlimited
Auto Dealer liability

Symbol 22 & 29Symbol 21
Deductible
Covered Autos Liability Each Accident
General Liability BI & PD Each Accident
Personal & Advertising Injury Any one or Organization
General Liability Aggregate Limit
Products & Work Performed Aggregate Limit
Loc & Operations Medical Payments Anyone Person
Auto Medical Payments Anyone Person
HiredBoard From ProductsAssault & battery Buyback
Personal Injury Protection Limit per status
Uninsured Motorists Coverage Each Acc.
Underinsured Motorists Coverage Each Acc.
Uninsured Motorists Property Damage Each Acc.
# of Dealer Plates :
Additional Insureds

Lessor of Leased Equipment (CA 2047)Grantor of Franchise (CA 2049)Owner of Leased or Rented Land or Premises(CA 2509)Designated Person or Organization (CAG 1712)Scheduled Person or Organization Primary and Non- Contributory (CAG 1752)Waiver of Subrogation (CA 0444)
Relationship to Insured
Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dealers Physical Damage

ComprehensiveSpecified CausesCollision
Limit Location 1
Maximum limit per Auto
Limit Location 2
Deductible per Auto
Limit Location 3
Vehicle Storage :

BuildingStandard Lot*Non-Standard Lot*Unprotected Lot*
Theft Buyback, for UnprotectedFalse Pretense
Types of Autos:

New AutosUsed Autos, Demonstrators,Service Vehicles
Interest(s) Covered (Check all that apply):

Your interest in covered autos you ownyour interest only in financed autosyour interest & interest of any creditor/ loss payeeConsigned Auto
Creditor / Loss payee Name
Creditor / Loss payee Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dealers Acts, Errors & Omissions:

Title E&OFederal Odometer E&OTruth In Lending E&OInsurance Agents E&O

NON DEALERS / SERVICE OPERATIONS

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NON-DEALER COVERAGES & LIMITS
Radius of pickup & delivery

0-25 Miles26-100 Miles101-200 MilesOver 200 Miles
Auto Only Each Accident
Other than Auto Each Accident
Other Than Auto Aggregate Limit
Personal Injury Liability Aggregate Limit
Broadened Coverage (include Personal Injury & 100.000 Damage to Rented Premises)
Damage to Rented Premises Any one Premises
Damage to Rented Premises Any one Person
Damage to Rented Premises Any one Person
Hired AutoBroad Form ProductAssault & Battery BuybackLiquor Liability buyback
Registration / Repairer / Transporter plates # of plates: Plates Numbers fields and text.
Personal Injury Protection Limit per Premises
Uninsured Motorists Coverage Each Acc.
Underinsured Motorists Coverage Each Acc.
Uninsured Motorists Property Damage blanks Each Acc.
Additional Insureds

Lessor of leased Equipment (CA 2047)Grantor of Franchise (CA 2049)Owner of Garage Premises (CA 2509)Designated Person or Organization (CAG 1912)Scheduled Person or Organization primary and Non Contributory (CAG 1952)Waiver of Subrogation (CA 0444)
Relationship to Insured :
Name :
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
GarageKeepers

Specified CausesComprehensiveCollision
Legal LiabilityDirect ExcessDirect Primary
Limit Location 1
maximum Limit Per Auto
Limit Location 2
Deductible Per Auto
Limit Location 3
Vehicle storage :

BuildingStandard Lot*Non-Standard Lot*Unprotected Lot*
Theft Buyback , for Unprotected Lot (Subject to guidelines)For - Hire - In - Tow Coverage Buyback (Subject to guidelines)
Number of Tow Trucks
SCHEDULED AUTO LIABILITY OR PHYSICAL DAMAGE COVERAGE

Available in AL, CA, MS, MO, NM, OH, SD, TN, TX, VA, WA, WY.
Coverage : (Check all that apply)

LiabilityUninsured/UnderinsuredPersonal Injury ProtectionPhysical Damage:Comprehensive & Collision, orSpecified Causes & Collision
Name:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Lessor - Additional Insured & Loss Payee Vehicle:
Year
Make & Model :
VIN :
GVW :
Radius of Operations Miles
Stated Value : $
Check all that apply :

Towing: For HireTowing : Not - For -HireTrailer or Tow DollyTrailer or Tow DollyPersonal Use
Year
Make & Model :
VIN :
GVW :
Radius of Operations Miles
Stated Value : $
Check all that apply :

Towing: For HireTowing : Not - For -HireTrailer or Tow DollyTrailer or Tow DollyPersonal Use
Year
Make & Model :
VIN :
GVW :
Radius of Operations Miles
Stated Value : $
Check all that apply :

Towing: For HireTowing : Not - For -HireTrailer or Tow DollyTrailer or Tow DollyPersonal Use
Year
Make & Model :
VIN :
GVW :
Radius of Operations Miles
Stated Value : $
Check all that apply :

Towing: For HireTowing : Not - For -HireTrailer or Tow DollyTrailer or Tow DollyPersonal Use
Year
Make & Model :
VIN :
GVW :
Radius of Operations Miles
Stated Value : $
Check all that apply :

Towing: For HireTowing : Not - For -HireTrailer or Tow DollyTrailer or Tow DollyPersonal Use
Should be Empty:

GARAGE & AUTO DEALER APPLICATION

ALL QUESTION MUST BE ANSWERED IN FULL, SIGNED AND DATED BY THE APPLICANT

Applicant Information

UNDERWRITING INFORMATION

Do You:

Do You:

PRIOR INSURANCE COMPANY AND LOSS HISTORY

DEALERS OPERATIONS

NON-DEALER COVERAGES & LIMITS

SCHEDULED AUTO LIABILITY OR PHYSICAL DAMAGE COVERAGE