GARAGE INSURANCE APPLICATION

Business Trade Name*

Owners Name(s)*

Mailing Address*

Mailing Address

Street Address Line 2

CityState

Zip Code

Same as Mailing?*

YesNo

Physical Address

Address

Street Address Line 2

CityState

Zip Code

Business Phone Number*

Cell Phone Number*

Email*

ejemplo@ejemplo.com

Years in business*

Years Experience*

Web address

Business type*

IndividualPartnershipLLCCorporation

Describe your business*

Requested Effective Date*

Fecha

Estimated Gross Sales for next 12 months (Revenues)*

Auto Repair Shop -Cars, SUV’s, pickups, vans %*

Auto Repair Shop -Comm. trucks & trailers %*

Auto Body Shop %*

Towing Services %*

Auto Salvage Operation %*

Auto Sales %*

Parts Store %*

RV Sales (Motor home, Camping Trailer)*

Motorcycle Sales and Service*

Other Describe*

Number of Employees

Including Owner

Number of Employees

Including owners

Name*

Date of Birth*

License Number & State*

Duties*

Example: Sales, Mechanic, Porter, Clerical, Contract Driver

Full or Part Time (20 hours or less)*

FTPT

Furnished Vehicle for take home?*

YN

Name

Date of Birth

License Number & State

Duties

Example: Sales, Mechanic, Porter, Clerical, Contract Driver

Full or Part Time (20 hours or less)

FTPT

Furnished Vehicle for take home?

YN

Name

Date of Birth

License Number & State

Duties

Example: Sales, Mechanic, Porter, Clerical, Contract Driver

Full or Part Time (20 hours or less)

FTPT

Furnished Vehicle for take home?

YN

Name

Date of Birth

License Number & State

Duties

Example: Sales, Mechanic, Porter, Clerical, Contract Driver

Full or Part Time (20 hours or less)

FTPT

Furnished Vehicle for take home?

YN

Name

Date of Birth

License Number & State

Duties

Example: Sales, Mechanic, Porter, Clerical, Contract Driver

Full or Part Time (20 hours or less)

FTPT

Furnished Vehicle for take home?

YN

Where do you purchase vehicles?

Who drives or transports vehicles to your lot?

Example: Auto Transporters, Contract Drivers

Do you drive newly acquired auto more than 200 road miles from point of purchase to your lot

How many trips a year?

Max miles per one-way trip?

Number of dealer plates used?

Do you lease or rent autos?

YN

Do you engage in sight unseen internet sales?

YN

Do you repossess autos?

YN

Lot Security

Any Dogs/Animals allowed/kept at any location?

YN

Where are keys kept?

Approved UL Booth?*

YN

Any Welding?*

YN

Approved UL Booth?*

YN

Garage Liability

Garage Keepers Limit

Customers Car in your care custody and control

Max Value of Any One Unit

Legal Liability (Pays claim you are negligent) or Direct Primary (Pays claim regardless of fault)

Legal LiabilityDirect Primary

Deductible

25050010002500

Dealers Open Lot - Inventory amount

How many vehicles are typically on your property overnight

Max Value of Any One Unit

Deductible

Number of Vehicles

Year

Make/Model

Vin #

Stated Value

On Hook/Cargo Limit

Year

Make/Model

Vin #

Stated Value

On Hook/Cargo Limit

Year

Make/Model

Vin #

Stated Value

On Hook/Cargo Limit

Year

Make/Model

Vin #

Stated Value

On Hook/Cargo Limit

Year

Make/Model

Vin #

Stated Value

On Hook/Cargo Limit

Deductible

Do you currently have insurance?

YN

Name of Insurance Company?

Current Premium

Any claims in past 3 yrs?

If yes provide loss runs (claim report)

Has you been cancelled or non renewed in past 3 yrs?

The undersigned, as a condition precedent to applying for insurance quotes hereby states that to the best of their knowledge, the above Statement of Losses includes all occurrences, accidents, or other events for which, under the terms of a Policy as set forth therein, a claim for coverage under the Policy could be made. The undersigned understands that the quoting company is relying solely upon the accuracy of this Certification of Statement of Losses as an inducement to receive competitive coverage, terms and preferred pricing. The undersigned further states and understands that if any such occurrence, accident or event is not disclosed above; the submission of this Certification of Statement of Losses by the undersigned constitutes a material misrepresentation, and will result in a company rescission making all quotes null and void. The undersigned, by signing this Certification, represents that he/she has the authority to make these representations with respects to the Statement of Losses to be used for obtaining insurance quotes.

Insured name

Date

Fecha

Signature

GARAGE INSURANCE APPLICATION

Applicant Information

Physical Address - Locations

Business Percentage of Operations:

Employee Information

Auto Sales Questions

Auto Repair Body Shop Questions

Scheduled Vehicles

IMPORTANT: PLEASE READ BEFORE SIGNING