Garage Application

Garage Application

To be able to save this form after the fields are filled in, you will need to have Adobe Reader 9 or later. If you do not have version 9 or later, please download the free tool at: http://get.adobe.com/reader/.

General Information

FEIN#:

Applicant name:

Doing business as (DBA):

Mailing address:

City: State: Zip Code:

Website address:

Contact name: Contact phone number:

Effective date: Expiration date:

Years in business:

If less than 3 years, please provide industry experience:

Lines of business

Property Garage/Auto Workers’ Comp EPLI Umbrella Other

Legal status

Individual Partnership Corporation LLC Other

Description of operations

Franchise auto dealer Non-franchise auto dealer Non-dealer (describe below)

General Rating Information

Misc. Coverage Information

Location Information

Location #1:

Same as mailing address Other, see below

Address:

City: State: Zip code:

Garagekeepers:

Garagekeepers limit per location: Maximum limit per auto:

Specified perils Comprehensive Collision Direct primary Direct excess Legal liability

Are vehicles stored overnight? Yes No Lot protection: Building Fenced Unprotected

Comprehensive deductible: $100/$500 $250/$1,000 $500/$2,500 $1,000/$5,000 $2,500/$12,500 $5,000/$25,000

Collision deductible: $100 $250 $500 $1,000 $2,500 $5,000

Dealers open lot:

Dealers open lot limit per location: Maximum limit per auto:

Specified perils Comprehensive Collision Standard open lot Non-standard open lot Building

Standard open lot: Open parking or storage lots enclosed on all sides by a metal cyclone fence not less than six feet in height or bounded on one or more sides by the wall or walls of a building with no unprotected opening and with exposed sides of the lot enclosed by a metal cyclone or equivalent fence not less than six feet in height, with opening securely locked when unattended.

Non-standard open lot: Any other type of protection or fencing or unprotected lot.

Comprehensive deductible: $100/$500 $250/$1,000 $500/$2,500 $1,000/$5,000 $2,500/$12,500 $5,000/$25,000

Collision deductible: $100 $250 $500 $1,000 $2,500 $5,000

Class of Employee

Employee count (complete employee list required)

Property

Location #: Building #:

Square feet: Year built: Number of stories:

Building updates:

Plumbing: Yes No Year of update: HVAC: Yes No Year of update:

Electrical: Yes No Year of update: Roof: Yes No Year of update:

Is electrical panel manufactured by either Zinsco or Federal Pacific? Yes No

Construction: FRAME JM NC Masonry NC Modified fire resistive Fire resistive

Is the building sprinklered? Yes No

Does the building have a fire alarm? Yes No Local alarm Central station

Does the building have a burglar alarm? Yes No Local alarm Central station

Deductible: $250 $500 $1,000 $2,500 $5,000 $10,000

Co-insurance: 80% 90% 100%

What is the building valuation based on?

What are desired BPP limits based on?

What are the annual sales?

False pretense: Yes No

Additional garage coverages:

Garage / Auto Coverage Information

Vehicle schedule if you have scheduled vehicles – for additional vehicles complete vehicle supplemental

Drivers list – for additional drivers complete driver list supplemental

Have any driver been convicted of a major violation in the last 3 years? Yes No

If yes, list drivers:

Survey of Hazards

General Underwriting Questions

1. Does applicant have an established store front? Yes No

2. Does applicant share a premises with any other occupants? Yes No

3. Any guard dogs on premises? Yes No

4. Is applicant a subsidiary of another entity or have any subsidiaries? Yes No

If yes, explain:

5. Does applicant subcontract any work? Yes No

If yes, explain:

6. Has coverage been declined, canceled or non-renewed in last 3 years? Yes No

If yes, explain:

7. Does applicant have any other business ventures not included in this submission? Yes No

If yes, explain:

8. Has applicant had a foreclosure, repossession or bankruptcy in the last 5 years? Yes No

9. Has applicant had a judgment in the last 5 years? Yes No

10. Are there currently serviced, charged and operable fire extinguishers on premises? Yes No

11. Does applicant store all flammable liquids in a UL-listed fire cabinet? Yes No

12. Does applicant use UL-listed metal containers with self closing lids? Yes No

13. Does applicant have no-smoking signs posted? Yes No

14. General housekeeping practices Moderate Formal Informal

15. Employee safety training practices Moderate Formal Informal

16. Describe type of mechanic certification (ie: ASE certified):

17. Describe key control procedures:

18. Does applicant have underground gasoline storage tanks? Yes No

If yes, please describe: Age of tanks: Tank construction:

Describe leak monitoring method:

Prior Carrier / Loss History (minimum 3 years)

Types of Vehicles

Paint and body shop operations

1. Is spray booth NFPA compliant? Yes No

2. Is booth protected by an automatic sprinkler or dry chemical fire suppression system? Yes No

3. Is paint mixing area enclosed in a non-combustible enclosure with self-closing metal door? Yes No

4. Is paint mixing area protected by an automatic sprinkler or dry chemical fire suppression system? Yes No

5. Does mixing area have explosion proof electrical systems? Yes No

6. NFPA compliant powered ventilation in booth and mixing room? Yes No

7. Are all filters regularly cleaned and changed? Yes No

8. Maximum gallons of flammable solvent based liquid maintained at any one time:

Please provide the following information to complete:

Date: