GARAGE / DEALER

Insured's Name:

Location Address:

Location City:

Location State:

SELECT DELAWARE MARYLAND NEW JERSEY PENNSYLVANIA VIRGINIA WASHINGTON DC

Location Zip Code:

Nature of Business:

Coverages Needed:

Dealer Liability:

SELECT YES

Non-Dealers Liability:

SELECT YES

GarageKeepers Legal:

SELECT YES

Dealers Open Lot:

SELECT YES

On-Hook:

SELECT YES

Gross Receipts:

Type of Units Sold:

SELECT PRIVATE PASSENGER LIGHT TRUCKS MEDIUM TRUCKS HEAVY TRUCKS TRACTOR / TRAILERS BOATS MOTORCYCLES RECREATIONAL VEHICLES

Number of Years in Business:

Number of Years Experience:

Does the Insured:

Does the Insured Spray-Paint:

SELECT YES NO

Modify Vehicles:

SELECT YES NO

Sponsor a Race Car:

SELECT YES NO

Provide Valet Services:

SELECT YES NO

Do any Welding:

SELECT YES NO

Repair Tires:

SELECT YES NO

Provide Salvage Operations:

SELECT YES NO

Provide Propane Gas:

SELECT YES NO

Do any Frame Straightening:

SELECT YES NO

Loan Vehicles:

SELECT YES NO

Repossess Vehicles:

SELECT YES NO

Hire Sub-Contractors:

SELECT YES NO

Number of Dealer Plates:

Number of R & S Tags:

Are Keys Controlled:

SELECT YES NO

Does an Employee always

accompany on Test Drives:

SELECT YES NO

Lot Protections:

Lighted:

SELECT YES NO

Fenced:

SELECT YES NO

Central Station Alarm:

SELECT YES NO

Any Guard Dogs:

SELECT YES NO

Are Guard Dogs kept in building after hours:

SELECT N/A YES NO

Does the Insured travel to Auctions:

SELECT YES NO

Mileage One-Way to Auctions:

SELECT NOT APPLICABLE LESS THAN 50 MILES 50 TO 100 MILES 100 TO 300 MILES OVER 300 MILES

How many trips to Auctions Annually:

Please list all Employees, Active, and/or Inactive Owners:

Date of

Years

License

License

Name

Birth

Experience

Job Duties

State

Number

Please list any Non-Employee furnished a Dealer Tag (Include Family Members):

Date of

Years

License

Name

Birth

Driving

Relationship

State

Please list all accidents and violations by driver name:

Number of Vehicles on the lot for Sale:

Number of Vehicles on the lot for Repair:

Coverages Requested:

Garage Liability Limits:

SELECT 100 / 300 300 / 600 500 / 1 MILL 1 MILL / 2 MILL

Garagekeepers Legal Liability:

Per Vehicle Limit:

Lot Limit per Location:

Dealers Open Lot:

Per Vehicle Limit:

Lot Limit per Location:

On-Hook Coverage:

Per Vehicle Limit:

How many Vehicles

on Truck at One Time:

Is Insured contracted by a motorclub for towing:

SELECT YES

Is towing 100% for hire (no repair work):

SELECT YES

Does Insured have an impound lot:

SELECT YES

Deductible Requested:

SELECT $500 $1000 $2500 $5000

Prior Insurance Carrier:

Last Years Premium:

Please provide details of any losses for the past 5 years:

Would the Insured like Building or Contents Coverage:

SELECT YES NO

Building Limits:

Contents Limits:

Is there any additional information you would like us to know about this risk:

Agency Name:

Agency Address:

Agency Phone:

Agency Fax:

Agency Contact:

Contact E-Mail Address:

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