Garage Application Form

First Name

Last Name

Email Address

Contact Number

Business Name

DBA

Owner/s (include all)

Business Entity Business Entity Individual Corporation Partnership Limited Liability Corp. Other

Mailing Address

City

State

Zip / Postal Code

Inspection Contact Name

Inspection Contact Number

Website

Dealer ID Number

Years in business

Years of experience

Explain in detail prior experience and any specialized training or certification

Briefly describe operations

Type all locations and operations in those locations. (Physical Street Address, City, State, Zip - Operations)

Current Carrier

Current Carrier Policy Dates

Current Carrier Premium

Do you have prior coverage? Do you have prior coverage? Yes No

Prior Carrier

Prior Carrier Policy Dates

Prior Carrier Premium

Prior Carrier

Prior Carrier Policy Dates

Prior Carrier Premium

Do you have prior losses? Do you have prior losses? Yes No

Date of Loss

Amount Paid / Reserve

Description including driver

Status

Have you had insurance for this type of operation cancelled, declined or non-renewed in the past three years? Have you had insurance for this type of operation cancelled, declined or non-renewed in the past three years? Yes No

If yes, please explain

Are any animals maintained on premises? Are any animals maintained on premises? Yes No

Describe type / breed of animals

Do you have serviced and changed fire extinguishers on site? Do you have serviced and changed fire extinguishers on site? Yes No

Do you leave keys in vehicles? Do you leave keys in vehicles? Yes No

Are keys kept in a secure room location with no access by unauthorized persons? Are keys kept in a secure room location with no access by unauthorized persons? Yes No

Are autos stored on premises after normal business hours? Are autos stored on premises after normal business hours? Yes No

Do you ever park your owned vehicles or a customer’s vehicle on the street? Do you ever park your owned vehicles or a customer’s vehicle on the street? Yes No

Are signs posted to keep customers from work area? Are signs posted to keep customers from work area? Yes No

Is any work performed off-premises (i.e., roadside or customer’s location)? Is any work performed off-premises (i.e., roadside or customer’s location)? Yes No

If yes, what percentage of operations are mobile?

Describe your vehicle theft barrier/storage for location 1 Describe your vehicle theft barrier/storage for location 1 None Fence & Gate Post & Cable In Building Other

Describe

Describe your vehicle theft barrier/storage for location 2 Describe your vehicle theft barrier/storage for location 2 Not applicable None Fence & Gate Post & Cable In Building Other

Describe

Describe your vehicle theft barrier/storage for location 3 Describe your vehicle theft barrier/storage for location 3 Not applicable None Fence & Gate Post & Cable In Building Other

Describe

Number of employees (including owners)

Employee 1 Full Name

Assigned Location

DL Number

DOB

CDL

Status

Violations/Accidents Prior Three Years, please describe

Job Duties

Others, please specify

Auto Usage Auto Usage Furnished a covered auto for personal use Uses a covered auto strictly for business use Excluded Driver

Personal Auto Policy in place? Personal Auto Policy in place? Yes No

Employee 2 Full Name

Assigned Location

DL Number

DOB

CDL

Status

Violations/Accidents Prior Three Years, please describe

Job Duties

Others, please specify

Auto Usage Auto Usage Furnished a covered auto for personal use Uses a covered auto strictly for business use Excluded Driver

Personal Auto Policy in place? Personal Auto Policy in place? Yes No

Employee 3 Full Name

Assigned Location

DL Number

DOB

CDL

Status

Violations/Accidents Prior Three Years, please describe

Job Duties

Others, please specify

Auto Usage Auto Usage Furnished a covered auto for personal use Uses a covered auto strictly for business use Excluded Driver

Personal Auto Policy in place? Personal Auto Policy in place? Yes No

Employee 4 Full Name

Assigned Location

DL Number

DOB

CDL

Status

Violations/Accidents Prior Three Years, please describe

Job Duties

Others, please specify

Auto Usage Auto Usage Furnished a covered auto for personal use Uses a covered auto strictly for business use Excluded Driver

Personal Auto Policy in place? Personal Auto Policy in place? Yes No

Employee 5 Full Name

Assigned Location

DL Number

DOB

CDL

Status

Violations/Accidents Prior Three Years, please describe

Job Duties

Others, please specify

Auto Usage Auto Usage Furnished a covered auto for personal use Uses a covered auto strictly for business use Excluded Driver

Employee 6 Full Name

Personal Auto Policy in place? Personal Auto Policy in place? Yes No

Assigned Location

DL Number

DOB

CDL

Status

Violations/Accidents Prior Three Years, please describe

Job Duties

Others, please specify

Auto Usage Auto Usage Furnished a covered auto for personal use Uses a covered auto strictly for business use Excluded Driver

Personal Auto Policy in place? Personal Auto Policy in place? Yes No

Employee 7 Full Name

Assigned Location

DL Number

DOB

CDL

Status

Violations/Accidents Prior Three Years, please describe

Job Duties

Others, please specify

Auto Usage Auto Usage Furnished a covered auto for personal use Uses a covered auto strictly for business use Excluded Driver

Personal Auto Policy in place? Personal Auto Policy in place? Yes No

Employee 8 Full Name

Assigned Location

DL Number

DOB

CDL

Status

Violations/Accidents Prior Three Years, please describe

Job Duties

Others, please specify

Auto Usage Auto Usage Furnished a covered auto for personal use Uses a covered auto strictly for business use Excluded Driver

Personal Auto Policy in place? Personal Auto Policy in place? Yes No

Employee 9 Full Name

Assigned Location

DL Number

DOB

CDL

Status

Violations/Accidents Prior Three Years, please describe

Job Duties

Others, please specify

Auto Usage Auto Usage Furnished a covered auto for personal use Uses a covered auto strictly for business use Excluded Driver

Personal Auto Policy in place? Personal Auto Policy in place? Yes No

Employee 10 Full Name

Assigned Location

DL Number

DOB

CDL

Status

Violations/Accidents Prior Three Years, please describe

Job Duties

Others, please specify

Auto Usage Auto Usage Furnished a covered auto for personal use Uses a covered auto strictly for business use Excluded Driver

Personal Auto Policy in place? Personal Auto Policy in place? Yes No

Annual Receipts: Uninstalled Part Sales ($)

Annual Receipts: Accessory Sales ($)

Annual Receipts: Car Wash Sales ($)

Annual Receipts: Clothing Sales ($)

Annual Receipts: Concessionaires ($)

Annual Receipts: Convenience Store Sales ($)

Annual Receipts: Gasoline Sales Full Service ($)

Annual Receipts: Gasoline Sales Self Service ($)

Annual Receipts: Gasoline - Number of Gallons Sold

Annual Receipts: LPG/Propane Butane Sales ($)

Annual Receipts: Machine Shops ($)

Annual Receipts: Manufacturing/Fabrication ($)

Annual Receipts: Repair ($)

Annual Receipts: Salvage Parts ($)

Annual Receipts: Self Park Sales ($)

Annual Receipts: Tire Sales - New ($)

Annual Receipts: Tire Sales - Used ($)

Annual Receipts: Tire Sales (not installed) ($)

Annual Receipts: Vehicle Sales ($)

Annual Receipts: Welding ($)

Annual Receipts: Other ($)

Do you lease or rent vehicles to others? Do you lease or rent vehicles to others? Yes No

Do you have coverage elsewhere for this operation/exposure? Do you have coverage elsewhere for this operation/exposure? Yes No

Do you provide /offer autos loaned to customers? (Does not apply to test drives) Do you provide /offer autos loaned to customers? (Does not apply to test drives) Yes No

Is there a contract agreement? Is there a contract agreement? Yes No

Do you get a copy of the driver's license? Do you get a copy of the driver's license? Yes No

Do you verify that the customer has auto insurance? Do you verify that the customer has auto insurance? Yes No

What is the minimum age?

Do you own, work on, sponsor or advertise any vehicles used in racing events? Do you own, work on, sponsor or advertise any vehicles used in racing events? Yes No

Provide details

Do you have an ownership interest in or operate any other business? Do you have an ownership interest in or operate any other business? Yes No

Provide business name and physical address

Describe the operation of the business

What is the relationship between the business in question and the business we are being asked to insure?

Do you rent space at this location to another business? Do you rent space at this location to another business? Yes No

If Yes, what is the nature of that business?

Do renters carry their own insurance? Do renters carry their own insurance? Yes No

Do you store all paints and solvents in a fire resistive cabinet outside the paint booth/room? Do you store all paints and solvents in a fire resistive cabinet outside the paint booth/room? Yes No

Any firearms on premises? Any firearms on premises? Yes No

Do you use any subcontractors? Do you use any subcontractors? Yes No

If Yes, do you obtain certificates of insurance? If Yes, do you obtain certificates of insurance? Yes No

New Field

Do you tow or hire? (If yes, complete Tow Truck Questionnaire) Do you tow or hire? (If yes, complete Tow Truck Questionnaire) Yes No

Do you hold FMSCA permit or DOT registration? Do you hold FMSCA permit or DOT registration? Yes No

If yes, provide: US DOT# MC#

Do you have Transporter or Repairer Plates (Non-dealer)? Do you have Transporter or Repairer Plates (Non-dealer)? Yes No

If yes: How many do you have ?

How are they used?

List plate numbers:

Do you drive customers' vehicles for purpose of pick up and/or delivery? Do you drive customers' vehicles for purpose of pick up and/or delivery? Yes No

If yes, what radius?

How many times per week?

Do you allow customers to drive vehicles into the service bay? Do you allow customers to drive vehicles into the service bay? Yes No