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APPLICATION FOR GARAGE POLICY (Risk Placement Services, Inc.)

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CGZ-APP-6 (11-16) Page 1 of 11
APPLICATION FOR GARAGE POLICY
Proposed Policy Period: From: To:
Named Insured: DBA:
Mailing Address: City:
County: State: Zip Code: Phone:
Internet Address (If any): FEIN:
Inspection/Audit Contact Name and Telephone Number:
Years in Business: Years Sales/Repair Experience:
Have you ever operated a garage business under another name?................................................................... Yes No
If yes, explain:
Business Entity: Individual Partnership Corporation Other:
Describe your Operations:
Do you engage in any other operations? ........................................................................................................... Yes No
If yes, explain:
Are you a licensed auto dealer?......................................................................................................................... Yes No
Dealer ID No.:
License Type: Retail Wholesale Distributor Other:
Locations/Premises where you conduct Garage Operations:
1.
2.
Do you own or lease Location 1? ................................................................................................................. Own Lease
Do you own or lease Location 2? ................................................................................................................. Own Lease
GENERAL INFORMATION
1. What are your normal business hours?
2. Are autos stored at your premises after normal business hours? ............................................................... Yes No
CGZ-APP-6 (11-16) Page 2 of 11
a. If
yes, describe your theft barriers/storage at each location for autos you OWN (building, fence and gate or post
and cable):
Location 1:
Location 2:
b. If yes, describe your theft barriers/storage at each location for autos you do not OWN (building, fence and gate or
post and cable):
Location 1:
Location 2:
c. Owned Auto Values (Dealers Physical Damage):
Maximum Value
of ALL Autos
Average Value
per Auto
Maximum Value
per Auto
Average No.
of Autos
Maximum No.
of Autos
Location No. 1 $ $ $
Location No. 2 $ $ $
d. Nonowned Auto Values (Garagekeepers):
Maximum Value
of ALL Autos
Average Value
per Auto
Maximum Value
per Auto
Average No.
of Autos
Maximum No.
of Autos
Location No. 1 $ $ $
Location No. 2 $ $ $
3. Do you have or maintain animals on your premises? ................................................................................. Yes No
If yes, what types/breeds?
Are these animals: Pets Used for Security Purposes Professionally Trained
Are warning signs posted? .......................................................................................................................... Yes No
Where are they kept during business hours?
4. Total Gross Receipts from:
All Vehicle/Equipment Sales: ...................................................................................................................... $
All Repair: ................................................................................................................................................... $
Other Uninstalled Product Sales: ............................................................................................................... $
Tow Truck Operations: ............................................................................................................................... $
5. 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):
6. Do you pick up or deliver autos not owned by you? .................................................................................... Yes No
If yes, how many times per week? What is the average and maximum radius traveled?
7. Do you tow for hire?..................................................................................................................................... Yes No
If yes, explain:
8. Who drives or tows vehicles to your premises?
9. Do employees use their own vehicles within the scope of their employment? ........................................... Yes No
If yes, how many times per week? What is the average and maximum radius traveled?
10. Do you obtain certificates of insurance from all sub-contractors utilized (transporters, etc.)? ...... N/A Yes No
11. Do you utilize unscheduled contract drivers? .............................................................................................. Yes No
If yes, do you verify that they have valid U.S. driver licenses? ................................................................... Yes No
How many per: Week: Month: Year:
CGZ-APP-6 (11-16) Page 3 of 11
12. D
o you loan or lease autos to others? ......................................................................................................... Yes No
Do you loan autos to customers while their auto is being repaired? ........................................................... Yes No
If yes, provide copy of agreement.
13. How many plates do you have or do you plan to procure in the next twelve (12) months?
Dealer: Dealer plate numbers:
Registration/Transporter: Transporter plate numbers:
Describe how plates are being used:
Where are plates stored when not in use?
Do you sell, loan, or rent plates to others? .................................................................................................. Yes No
If yes, explain:
14. Do you perform operations or have driving exposures in the following states?
New York New Jersey Michigan Illinois Other (besides state of domicile)
If yes, describe:
15. 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
16. 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? .............................................................................................................
17. Do you own and/or sponsor any vehicles used in racing events? .............................................................. Yes No
If yes, provide details:
18. List ALL Owners, Employees and Drivers/Contract Drivers:
(Full Time = over twenty [20] hours/week)
Name DOB
Driver’s
License
No.
State
of
DL
CDL?
Funished
Auto?
Y/N
Works
at Loc.
No.
Violations
and
Accidents
Past
Three Years
Full
or
Part
Time
Job Title/
Duties
Y/N
Class
CGZ-APP-6 (11-16) Page 4 of 11
19. L
ist ALL Family members and non-family members, including all persons that have access to covered vehicles (ex-
cept customers):
Name DOB
Driver’s
License
No.
State
of
DL
Will drive
for or
Work in
business?
Y/N
Furnished
Auto?
Y/N
Violations
and
Accidents
Past
Three Years
Relationship
20. Have all drivers, such as children away from home or in college, who may operate your vehi-
cles on a regular or infrequent basis, been listed on this application? ........................................... Yes No N/A
21. Provide your percentage of operations (Percentages MUST equal one hundred percent [100%]):
* Requires completed supplemental application Repair Sales
Private passenger cars, SUVs, pick-up trucks, vans % %
Motor Homes % %
Motorcycles* % %
Buses* % %
Watercraft (boats, jet skis, etc.) % %
Dirt Bikes or ATVs/UTVs and all other recreational autos* % %
Farm Equipment % %
Construction/Contractor’s Equipment* % %
Travel trailers or camper trailers % %
Utility trailers or livestock trailers % %
Trucks, tractors, semi-trailers* % %
Salvage parts % %
Other: % %
TOTAL 100% 100%
UNDERWRITING INFORMATION—DEALERS (if no dealer operations, proceed to SERVICE)
22. Where do you purchase vehicles?
Do you buy or sell vehicles on the Internet? ............................................................................................... Yes No
If yes, explain:
23. Do you drive-away more than three hundred (300) miles from point of purchase? .................................... Yes No
If yes, how often and to where?
24. How many vehicles do you sell per year? ..................................................................................................
Retail: % Wholesale: % Consignment (attach consignment agreement): %
25. Do you export autos?................................................................................................................................... Yes No
If yes, are titles transferred prior to the auto leaving your care for shipping? ............................................. Yes No
CGZ-APP-6 (11-16) Page 5 of 11
26. Are titles transferred to customer upon relinquishing a sold vehicle? .........................................................
Yes No
If no, explain?
27. Do you require personal auto insurance to be in place prior to relinquishing a sold vehicle? .................... Yes No
28. Test drives:
Do you always obtain a copy of the customer’s license? ............................................................................ Yes No
Do you obtain proof of insurance when available? ...................................................................................... Yes No
Do you always ride along? .......................................................................................................................... Yes No
Do you permit overnight test drives? ...........................................................................................................
Yes No
UNDERWRITING INFORMATION—SERVICE (if no service operations, proceed to INSURANCE HISTORY)
29. List the percentage of your work (Percentages MUST equal one hundred percent [100%]):
Type of Work Percent Type of Work Percent
Oil and Lube % Wash/Detail %
Tune-Up % Window Tint %
Muffler % Clear Coating %
Radiator % Stereo System %
Electrical % Alarm System %
Brakes % Transmission %
Hitches: Bolt on Weld On % Windshield %
Upholstery % Lift Kit Installation %
Tires (New) % Suspension (Not Lift Kits) %
Tires (Used) % Wheel Alignment %
Frame Work % Performance Adjustments %
Painting % LPG %
Body Work % Other: %
30. Do you have quality control checks in place to ensure that repairs have been performed properly? ......... Yes No
31. Are signs posted to keep customers out of the work area? ........................................................................ Yes No
32. Do you do any welding? .............................................................................................................................. Yes No
Inside Outside Mobile Safeguards:
33. Do you have a spray paint booth? ............................................................................................................... Yes No
Is it U/L approved?....................................................................................................................................... Yes No
Is there an exhaust ventilation system? ...................................................................................................... Yes No
Are lighting/fixtures explosion proof? ........................................................................................................... Yes No
Is paint stored in fire-resistive cabinets outside the paint booth? ................................................................ Yes No
34. Is a frame straightening machine used?...................................................................................................... Yes No
Make/Model:
35. Any frame cutting/stretching? ...................................................................................................................... Yes No
CGZ-APP-6 (11-16) Page 6 of 11
INSURANCE HISTORY
3
6. Has your insurance been cancelled or non-renewed within the last three years? (Not applicable in
Missouri) ...................................................................................................................................................... Yes No
a. If yes, explain:
b. A minimum of three year history is required. If three year history is unavailable, 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
$
Date of Loss Amount Description of Loss
$
$
$
$
COVERAGES REQUESTED
37. Check applicable box(es):
GARAGE LIABILITY:
Each Accident Limit: $ Aggregate Limit: 1x 2x 3x
Deductible: ..................................................................................................................................... $
MEDICAL PAYMENTS: Applicable to: Garage Operations Autos Both
Limits: $500 $1,000 $2,500 $5,000
UNINSURED MOTORIST: $ PERSONAL INJURY PROTECTION: $
ADDITIONAL INSURED:
Address:
Explain the relationship there will be between the named insured and the additional insured:
GARAGEKEEPERS (Coverage for customers’ vehicles while in your care, custody and control):
Legal Liability Direct Primary
Maximum Limit Per Vehicle:........................................................................................................... $
Causes of Loss: Specified Causes w/Collision Comprehensive w/Collision
Total Limits: Location No. 1: ............................................................................................. $
Location No. 2: ............................................................................................. $
Deductibles: Specified Causes or Comprehensive Deductible: ........................................ $
Collision Deductible: ..................................................................................... $
Maximum Deductible Per Loss: .................................................................... $
In-Transit Limits (On-Hook): $ per auto (Garagekeepers coverage required to qualify for coverage)
Number of autos being towed or carried per each transporter:
CGZ-APP-6 (11-16) Page 7 of 11
DEALERS PHYSICAL DAMAGE (Coverage for damage to autos while held for sale):
Maximum Limit Per Vehicle:........................................................................................................... $
Causes of Loss: Specified Causes w/Collision Comprehensive w/Collision
Total Limits: Location No. 1: ............................................................................................. $
Location No. 2: ............................................................................................. $
Deductibles: Specified Causes or Comprehensive Deductible: ........................................ $
Collision Deductible: ..................................................................................... $
Maximum Deductible Per Loss: .................................................................... $
Type: New Used
Interests Covered: Owner Owner and Creditor (Bank) Consignment
Other Limits: At Temporary Locations: $ While in Transit: $
Loss Payee:
Loss Payee Address:
Drive-away Miles (if over three hundred [300] miles): .....................................................................
SPECIFICALLY DESCRIBED AUTOS:
Vehicle
No.
Year Make Body Type VIN ACV GVW
1
2
3
Vehicle
No.
Radius
Personal
Service or
Commercial
Use?
Filings Required Coverages Desired? Y/N
Loss Payee
Yes/No
State/
Federal
Liability
Physical
Damages
Other
1
2
3
ADDITIONAL COVERAGES REQUESTED
38. Check applicable box(es):
Registration Plates Not Issued For A Specific Auto (Max $100,000 limit available)
False Pretense: $25,000 $50,000 Other: $
Personal Injury Liability
Damage To Rented Premises Liability: $50,000 $100,000 $300,000
Broadened Coverage (Includes Personal Injury Liability and Damage To Rented Premises):
$50,000 $100,000 $300,000
Drive Other Car (Dealers only; Individuals included for this coverage must be rated as furnished)
Federal Odometer Errors and Omissions
Auto Dealer’s Error and Omissions (Includes Truth-In-Lending, Odometer and Title E&O)
Remarks:
CGZ-APP-6 (11-16) Page 8 of 11
PROPERTY INFORMATION
39
. Location where you conduct garage operations:
40. Coverage/Valuation Requested:
Subject of
Insurance
Amount
Co-Insurance
Percent
Protection
Class
Valuation:
ACV
or RC
Coverage
Form: Basic,
Broad or
Special
Deductible
Building Coverage
Building 1 $ $
Building 2 $ $
Business Personal
Property
Building 1 $ $
Building 2 $ $
Business Income:
Building 1
With Extra
Expense
$ $
Without Extra
Expense
$ $
Building 2
With Extra
Expense
$ $
Without Extra
Expense
$ $
41. Building Information:
Building
No.
Building
Age
Building
Constr.
Total
Sq. Ft.
Building
Total
Sq. Ft.
Occupied
No. of
Stories
Sprinkler
System
Fire
Protection
System
Burglar Alarm—
Type
Yes
No
Yes
No
Central Station
Local
Yes
No
Yes
No
Central Station
Local
Yes
No
Yes
No
Central Station
Local
42. Building Improvements: (Provide year updated)
Wiring Roof Plumbing HVAC Other
Building 1
Building 2
CGZ-APP-6 (11-16) Page 9 of 11
FRAUD WARNING: A
ny 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. (Not applicable in AL, CO, DC, FL, KS, LA, ME, MD, MN, NE, NY,
OH, OK, OR, RI, TN, VA, VT or WA.)
NOTICE TO ALABAMA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to restitution fines or confinement in prison, or any combination thereof.
NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or
information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may
include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance
company who knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant for
the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award pay-
able from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory
Agencies.
WARNING TO DISTRICT OF COLUMBIA APPLICANTS: It is a crime to provide false or misleading information to an
insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In
addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the
applicant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any insur-
er files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a
felony of the third degree.
NOTICE TO KANSAS APPLICANTS: Any person who, knowingly and with intent to defraud, presents, causes to be
presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or
any agent thereof, any written, electronic, electronic impulse, facsimile, magnetic, oral, or telephonic communication or
statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or
commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal
insurance which such person knows to contain materially false information concerning any fact material thereto; or con-
ceals, 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.
NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be sub-
ject to fines and confinement in prison.
NOTICE TO MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an
insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of
insurance benefits.
NOTICE TO MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent claim for
payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty
of a crime and may be subject to fines and confinement in prison.
NOTICE TO MINNESOTA APPLICANTS: A person who files a claim with intent to defraud or helps commit a fraud
against an insurer is guilty of a crime.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he is facilitating a fraud against
an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
NOTICE TO OKLAHOMA APPLICANTS: Any person who knowingly, and with intent to injure, defraud or deceive any
insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading infor-
mation is guilty of a felony.
CGZ-APP-6 (11-16) Page 10 of 11
NOTICE TO RHODE ISLAND APPLICANTS:
Any person who knowingly presents a false or fraudulent claim for payment
of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to fines and confinement in prison.
CGZ-APP-6 (11-16) Page 11 of 11
FRAUD WARNING (APPLICABLE IN VERMONT, NEBRASKA AND OREGON):
Any person who intentionally presents
a materially false statement in an application for insurance may be guilty of a criminal offense and subject to penalties
under state law.
FRAUD WARNING (APPLICABLE IN TENNESSEE, VIRGINIA AND WASHINGTON): It is a crime to knowingly provide
false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penal-
ties include imprisonment, fines, and denial of insurance benefits.
NEW YORK AUTOMOBILE FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance
company or other person files an application for commercial insurance or a statement of claim for any commercial or
personal insurance benefits containing any materially false information, or conceals for the purpose of misleading, infor-
mation concerning any fact material thereto, and any person who, in connection with such application or claim, knowingly
makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, dam-
age or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or an insurance
company, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed
five thousand dollars and the value of the subject motor vehicle or stated claim for each violation.
NEW YORK OTHER THAN AUTOMOBILE 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 shall also be subject to a civil penalty not to exceed five thousand dollars
and the stated value of the claim for each such violation.
This application does not bind the applicant or the Company to an agreement. However, the information stated on the
application shall be the basis of the contract should a policy be issued. The application does not provide coverage or limits
and may reflect different coverages or limits than offered by the Company.
FRAUD WARNINGS: Attach completed WHI APP-152, State Fraud Notification Compliance form.
APPLICANT’S NAME:
APPLICANT’S SIGNATURE: DATE:
(Authorized owner, partner or executive officer)
RETAIL AGENT NAME:
ADDRESS:
PRODUCER’S NAME: DATE:
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APPLICATION FOR GARAGE POLICY (Risk Placement Services, Inc.)

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Completed 7 February 2021

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