Application for Garage Policy

APPLICATION FOR GARAGE POLICY

Policy Period Desired: From To

Business Trade Name:   Insured:

Mailing Address:   City:

County:   State:   Zip Code:   Phone:

Internet Address (If any):

Years in Business:   Years Sales/Repair Experience:   Business Entity: Individual Partnership Corp.

Describe your Operations:

Locations/Premises where you conduct Garage Operations

1.   2.

GENERAL INFORMATION

A. What are your normal business hours?

Are autos stored at your premises after normal business hours? Yes No

If yes, describe your theft barriers/storage at each location, for autos you OWN (building, fence & gate or post & cable)

1.   2.

Describe your theft barriers/storage at each location, for autos you do NOT OWN (building, fence & gate or post & cable)

1.   2.

Do you own or lease Location 1? Own Lease   Do you own or lease Location 2? Own Lease

B. Do you have or maintain animals on your premises? Yes No

If yes, what types/breeds?

Are this/these animals pets? Yes No

Are they used for security purposes? Yes No

Do you maintain any other security measures not already listed? Yes No

If yes, explain:

C. Please provide value and number of autos stored at each location:

D. Describe your key controls during business hours:   After business hours:

If a key box is used, describe location of key box (in building or attached to autos):

E. Do you pick up or deliver autos not owned by you? Yes No

If yes, explain:

Do you tow for hire? Yes No

If yes, explain:

F. Who drives or tows vehicles to your premises?

G. What is your normal radius of operations?

H. Do you Loan or Lease autos? Yes No

If yes, do you loan or lease autos to customers while their auto is being repaired? Yes No

Do you loan or lease autos for shorter than 12 months? Yes No

I. Do you sell or store salvaged autos? Yes No

If yes, please indicate the purpose:

Sale of Salvage Titled Autos   Rebuilding/Repairing Customers Autos

Sale of Used Parts   Other   Explain:

J. List ALL Owners, Employees & Drivers

K. List ALL Family members and non-family members (except customers):

(Indicate if they are furnished an auto for personal use or if they may be provided an auto for regular use, but not regularly furnished.)

L. Will anyone listed in either Items J. or K. use an auto for reasons other than listed? Yes No

If yes, please explain:

M. Have all members of your household been disclosed on this application? Yes No

If no, explain:

N. Have all drivers, such as children away from home or in college, who may operate your vehicles on a regular or infrequent basis, been listed on this application? Yes No N/A

INSURANCE HISTORY

Has your insurance been cancelled or non-renewed within the last 3 years (not applicable in MO)? Yes No

If yes, please explain:

A minimum of 3 year history is required. If 3 year history is unavailable, please explain:

Current Carrier:   Eff. Date:   Exp. Date:   Policy Premium:

Prior Carrier:   Eff. Date:   Exp. Date:   Policy Premium:

Prior Carrier:   Eff. Date:   Exp. Date:   Policy Premium:

UNDERWRITER INFORMATION

Please provide your percentage of operations (Percentages MUST equal 100%).

Total Gross Receipts from:

All Vehicle/Equipment Sales $   All Repair $   Other Product Sales $

Tow Truck Operations $

All Vehicle/Equipment Sales Dealer / Sales Information

1. Where do you purchase vehicles?

Do you buy or sell vehicles on the Internet? Yes No

Explain:

2. Do you drive-away more than 300 miles from point of purchase? Yes No

If yes, how often?

3. How many vehicles do you sell per year?   How many of those are on consignment?

4. How many dealer plates do you have?

5. Do you repossess vehicles? Yes No

If yes, are these autos you have sold? Yes No

Do you repossess autos for banks or other dealers? Yes No

6. Test drives: Do you always obtain a copy of the customer’s license? Yes No

Do you always obtain proof of insurance? Yes No

Do you always ride along? Yes No

Auto Service/Repair/Installation Information

1. What percentage of your work is (Total of percentages must equal 100%):

2. Do you do any welding? Yes No

If yes, explain:

3. Do you have a spray paint booth? Yes No   If yes, is it U/L approved? Yes No

Is it ventilated? Yes No   Are fixtures covered/protected? Yes No

Is paint stored in fire-resistive cabinets outside the paint booth? Yes No

4. Do you sell gasoline? Yes No   If yes, how many gallons per year?

Do you sell LPG? Yes No   If yes, how many gallons per year?

5. Do you recap tires or sell recapped tires? Yes No

COVERAGE REQUESTED

GARAGE LIABILITY  $  $  Deductible $

GARAGEKEEPERS (Coverage for customers’ vehicles while in your care, custody & control)

Legal Liability Specified Causes w/ Collision Comprehensive w/ Collision

Total Limits: Location #1: $   Location #2: $

Deductibles: Spec. Causes or Comp. Ded. $   Collision Ded. $

Maximum Ded. Per Loss: $

In-Transit Limits (On-Hook): $ per auto (Garagekeepers coverage required to qualify for In-Transit Coverage)

DEALERS PHYSICAL DAMAGE (Coverage for damage to auto’s while held for sale)

Causes of Loss: Specified Causes w/ Collision Comprehensive w/ Collision

Total Limits: Location #1: $   Location #2: $

Deductibles: Spec. Causes or Comp. Ded. $   Collision Ded. $

Maximum Ded. Per Loss: $

Type: New Used   Interests Covered: Owner Owner and Creditor (Bank) Consignment

Drive-away Miles (If over 300 miles):

Other Limits: At Temporary Locations: $   While in Transit: $

Loss Payee:

Loss Payee Address:

PREMISES MEDICAL PAYMENTS $1,000 $5,000

SPECIFICALLY DESCRIBED AUTOS

UNINSURED MOTORIST $   PERSONAL INJURY PROTECTION $

FIRE LEGAL LIABILITY $50,000

Additional Insured:

Address:

Explain the relationship between the named insured and the additional insured:

Remarks:

FRAUD WARNING:

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

I understand that misrepresentation or omission of material facts will be cause for cancellation and may void coverage.

I have completed and signed a state form selecting or rejecting Uninsured / Underinsured Motorist Coverage.