GARAGE - AUTO DEALER, SERVICE AND REPAIR APPLICATION

DATE

RETAIL AGENCY

GENERAL AGENCY

AGENT NAME

PHONE NUMBER

APPLICANT'S NAME

PHONE NUMBER

MAILING ADDRESS

City

COUNTY

State

ZIP CODE

BUSINESS TRADE NAME

BUSINESS LEGAL ENTITY

INDIVIDUAL

PARTNERSHIP

LLC

CORPORATION

YEARS OF EXPERIENCE

REQUESTED EFFECTIVE DATE

YEARS IN BUSINESS

Locations where you conduct Garage Operations

LOCATION #1

ADDRESS
CITY
COUNTY
STATE
ZIP CODE

LOCATION #2

ADDRESS
CITY
COUNTY
STATE
ZIP CODE

LOCATION #3

ADDRESS
CITY
COUNTY
STATE
ZIP CODE

IS YOUR BUSINESS MOBILE IN NATURE?

Yes

No

INSURANCE HISTORY

PRIOR CARRIER
EFFECTIVE DATE
EXPIRATION DATE
POLICY PREMIUM

MARK BOX IF NO PRIOR INSURANCE

NO PRIOR INSURANCE

LOSS INFORMATION: If needed attach additional losses and details on a separate page

DATE OF LOSS
DEATAILS OF LOSS
AMOUNT PAID
AMOUNT RESERVED

MARK BOX IF NO PRIOR LOSSES

NO PRIOR LOSSES

1. Has your insurance been cancelled or non-renewed within the past three years?

Yes

No (n/a in MO)

2. Do you have or maintain animals on your premises?

Yes

No

If yes, please list type and breed

Are they

Pets

or Security?

3. Do you have or maintain firearms on your premises?

Yes

No

4. Do you participate in any ride share programs?

Yes

No

If yes, please explain

5. What are your hours of operation?

6. List your total annual gross receipts from:

Auto Sales
Auto Service / Repair
Retail Product Sales
Uninstalled Part Sales
Any other operations

7. Personnel: Please list all owners, employees, drivers and any family members or others who may have access to the autos.

Name
Date of Birth
Driver's License #
State
Class of CDL
# of Motor Vehicle violations past 3 years
Position
Auto Use
Status

Do you use any Contract Drivers in your business?

Yes

No

Business Operation Information:
Auto Section
By percentage list the types of autos sold, serviced or repaired in your Garage Operation. Percent total needs to be 100% per column.

Sales %

Private passenger, SUV, pick-up truck, and vans
All terrain vehicles, including dirt bikes
Antique or classic autos - typically over 30 years old
Bucket, boom trucks or cranes
Busses, motor coaches
Emergency Vehicles (ambulance, police and fire trucks)
Equipment (Farm, construction, earth moving, forklifts, and similar)
Golf Carts
Motorcycles / Scooters
Mobile Homes
Racing autos
Recreational Vehicles, Motorhomes
Refrigerated Autos
Trucks, Tractors, and semi-trailers, - greater than 26,000 lbs. gross vehicle weight
Utility Trailers
Watercraft
Any auto that has been modified for the physically impaired

Repair %

Option 1
Option 2
Option 3

9. What type of dealer license do you hold?

Retail

Wholesale

Dealer License #

State

10. Percentage of:

New Auto Sales
Used Auto Sales

11. Do you conduct auto auctions?

Yes

No

12. What percent of your auto sales are:

Retail
Wholesale
Consigned
Salvage Tile

13. Do you operate a salvage lot?

Yes

No

N/A

14. Do you use a consignment agreement for consigned autos?

Yes

No

N/A

15. Do you operate any auto pawn or title pawn operations?

Yes

No

16. Number of dealer plates you have

Number of other types of plates you have

17. If you are requesting Physical Damage coverage on your dealer's autos, the following must be completed

Location
Maximum Value per Auto
Average Value per Auto
Average # of autos on the lot
Maximum number of autos on the lot
Maximum value of all autos on the lot

Describe the theft protection for each location listed above

Location 1
Location 2
Location 3

18. Do you store autos away from the locations listed above?

Yes

No

If yes, where?

And for how long?

19. Are the keys or any device used to start or operate the auto, left in or upon the auto at any time?

Yes

No

Describe your key controls

During normal business hours
After business hours

When do you transfer the title of a sold auto?

At time of sale

Yes

No

When auto is paid for in full

Yes

No

When the state transfers title

Yes

No

Other

21. Do you pick up, deliver, or transport autos not owned by you?

Yes

No

22. Do you repossess autos for yourself?

Yes

No

For others

Yes

No

23. Do you export autos to other countries?

Yes

No

24. Do you loan or lease autos?

Yes

No

25. On test drives do you always: Obtain a copy of the customer's drivers license and proof of insurance?

Yes

No

Do you allow overnight test drives?

Yes

No

Ride along with customer?

Yes

No

Explain No answers

Non-Dealer Information
List the percentage of the type of work you do. Percentages must equal 100%

Type of Work - Percentage

Auto maintenance and repair - General type *
Auto conversion (any type)
Auto transporting
Dismantling
Ignition interlock systems (breathalyzer)
Frame work
Glass installation/repair/tint
Hitch installation
Hydraulics
Lift kit installation
Oil and lube
Painting or clear coating
Repossession
Self-Parking
Storage or impound
Suspension (not lift kits)
Wash or detail
Tires - New sales, service, installation, or repair
Tires - Use sales, service, installation, or repair Towing for hire
Upholstery
Valet Parking
Wrecker Service
Other
Other
Other

*Auto maintenance and repair includes the repair and replacement of standard auto parts, including, oil changes, battery replacement, brakes, tires, fluid check and fill, filters, belts, spark plugs, AC service, steering, suspension and transmission.

26. Are signs posted to keep customers out of work areas?

Yes

No

27. Do you do any welding?

Yes

No

If yes, please explain

28. Do you work on hydraulics for dump trucks, bucket trucks, boom trucks, scissor lifts, or any equipment that lifts people

Yes

No

29. Do you cut, stretch, or weld auto frames or forks?

Yes

No

30. Do you fabricate or manufacture any operating parts?

Yes

No

31. Do you custom build or manufacture any autos?

Yes

No

32. Do you have a paint booth?

Yes

No

Is it ventilated with explosion proof lighting?

Yes

No

33. Are paints stored in closed metal cabinet?

Yes

No

34. Do you use plates that are not issued for a specific auto?

Yes

No

If, yes how many do you have?

35. If you are requesting Garagekeepers coverage on your dealer's autos, the following must be completed

Location
Maximum Value per auto
Average value per auto
Average number of autos stored at each location
Maximum number of autos stored at each location
Maximum value of all autos stored at each location

Describe the theft protection for each location listed above

Location 1
Location 2
Location 3

36. Are the keys or any device used to start or operate the auto, left in or upon the auto at any time?

Yes

No

Describe your key controls

During normal business hours
After business hours

Coverage Requested

Liability

Covered Autos Liability
General Liability Bodily Injury and Property Damage Liability
Damages to Premises Rented to You
Personal and Advertising Injury Liability
General Liability Aggregate
Products and Work you Performed Aggregate
Liability Deductible

Locations and Operations Medical Payments - Any One Person

$500

$ 1,000

$ 2,000

$ 5, 000

Auto Medical Payments - Each Insured -

$500

$1, 000

$ 2,000

$5, 000

Acts, Errors or Omissions - For Dealers

Truth in Lending
Odometer Mileage
Title
Insurance Agent or Broker

Dealers Physical Damage Coverage (Wind, hail, or flood may not be available in all states)

Specified Cause of Loss and Collision

Comprehensive and Collision

Maximum Limit per Auto

$

Total Lot Limit per Location 1:

$

Location 2:

$

Location 3:

$

Deductibles per auto: Specified Cause of Loss or Comprehensive

$

Collision

$

Deductibles are subject to aggregates, and separate deductibles for wind, hail, or flood may apply.

Garagekeepers Coverage (Wind, hail or flood may not be available in all states)

Maximum Limit per Auto

$

Total Lot Limit per Location 1:

$

Location 2

$

Location 3

$

Deductibles per auto: Specified Cause of Loss or Comprehensive

$

Collision

$

Deductibles are subject to aggregates, and separate deductibles for wind, hail, or flood may apply.

No Fault Coverages - Not available in all states for all risks

(Must have a completed state specific selection/rejection form completed for proper coverage)

Limits and coverage options vary by state. This is to serve as a general indication that coverage is requested but does not guarantee coverage will be provided.

Uninsured Motorists / Underinsured Motorists Coverage
Personal Injury Protection

Additional optional coverage available (Additional charges may apply. Total number and additional information will be required for policy)

Additional Insureds

Lessor of Leased Equipment

Grantor of Franchise

Owners of Leased or Rented Land or Premises

Co-owner of Insured Premises

Concessionaires Trading Under Your Name

Controlling Interest

Grantor of Licenses

Grantor of Licenses - Automatic Status When Required by Licensor

Lessor of Leased Equipment - Automatic Status When Required in Lease Agreement with You

Other Options

Registration Plates Not Issued to Specific Auto

Waiver of Subrogation

Designated Insured

Applicant's Statement

Applicant hereby attests that the information contained herein is true and accurate to the best of his/her knowledge, information and belief.

Signature of Applicant / Title

Clear

Print Name

Date