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?
I am a(n)
Name
Phone
Format: (000) 000-0000.
Email
Applicant Information
Proposed Effective Date :

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

Other
Mailing Address :

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact:
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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

Rows	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
1
2
3
4
5
6
7
8
9
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?

INDICATE PERCENTAGE OF THE FOLLOWING TYPE OF AUTOS SOLD / REPAIRED

Rows
1
2
3
4
5
6
7
8
9
10
11
12

UNDERWRITING INFORMATION
How do you transport autos?
Towing capacity:
Do You:
Engage in any other operations?
Engage in fuel conversion?
Engage in performance enhancements?
Tow for hire?
Repossess vehicles for others?
Loan, Lease or Rent autos to others?
Engage in auto pawning or auto title loans?
Dismantle autos or have salvage operations?
Own or operate a car crusher?
Stack salvaged autos more than 2 high?
Work at airport, seaport or railroad premises?
Engage in Breathalyzer / ignition interlock?
Manufacture / Fabricate any auto parts?
Structurally alter or convert vehicles from their original factory design?
EXPLAIN ALL YES RESPONSES :
Do You:
Accompany customers in the service/repair area?
Secure all keys in a lock box or a secure cabinet away from vehicle?
Obtain certificates of insurance from all sub-contractors?
Are all paints and solvents stored in a fire resistive cabinet outside the paint booth?
Are all spray painting operations confined to an UL approved booth?
If No, is there explosion proof lighting and adequate ventilation?
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

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

Any policy or coverage Declined, Cancelled or Non-Renewed during the prior Three (3) years? (Missouri Applicants - Do not answer this question).
If Yes, Explain:
DEALERS OPERATIONS
Retail % Wholesale %
Internet % Auction %
Consigned %
Do you obtain Drivers License and proof of insurance before all test drives?
Are all test drivers accompanied by a salesperson?
Do you allow extended or overnight test drives?
Do you rent or loan dealer plates to others?
Do you offer in - house financing or Buy here / Pay Here?
If yes, are titles transferred to customer at the beginning of the finance period and your business named as a lienholder?
Radius of pickup & delivery
Auto Dealer liability
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
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
Relationship to Insured
Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dealers Physical Damage
Limit Location 1
Maximum limit per Auto
Limit Location 2
Deductible per Auto
Limit Location 3
Vehicle Storage :
Types of Autos:
Interest(s) Covered (Check all that apply):
Creditor / Loss payee Name
Creditor / Loss payee Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dealers Acts, Errors & Omissions:

NON DEALERS / SERVICE OPERATIONS

Rows	1	2	3	4
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19

NON-DEALER COVERAGES & LIMITS
Radius of pickup & delivery
Auto Only Each Accident
Other than Auto Each Accident
Other Than Auto Aggregate Limit
Personal Injury Liability Aggregate Limit
Damage to Rented Premises Any one Premises
Damage to Rented Premises Any one Person
Damage to Rented Premises Any one Person
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
Relationship to Insured :
Name :
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
GarageKeepers
Limit Location 1
maximum Limit Per Auto
Limit Location 2
Deductible Per Auto
Limit Location 3
Vehicle storage :
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)
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 :
Year
Make & Model :
VIN :
GVW :
Radius of Operations Miles
Stated Value : $
Check all that apply :
Year
Make & Model :
VIN :
GVW :
Radius of Operations Miles
Stated Value : $
Check all that apply :
Year
Make & Model :
VIN :
GVW :
Radius of Operations Miles
Stated Value : $
Check all that apply :
Year
Make & Model :
VIN :
GVW :
Radius of Operations Miles
Stated Value : $
Check all that apply :
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