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Acceptance Indemnity Insurance Company Occidental Fire & Casualty (Risk Placement Services, Inc.)

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AG 59 19 01 18 Page 1 of 7
GARAGE APPLICATION
Acceptance Indemnity Insurance Company Occidental Fire & Casualty Company of North Carolina
Acceptance Casualty Insurance Company Wilshire Insurance Company
Please answer ALL questions.
Incomplete or missing answers may cause processing delays or decline of coverage.
Requested policy period: Effective Date: Expiration Date:
1. APPLICANT INFORMATION
a. Form of business:
Individual Corporation Partnership Joint Venture Other:
b. Applicant/Named Insured:
(DBA):
c. Mailing Address:
d. Garage Locations:
Loc#
Address
City
State
Zip
Lot Protection
1
Building
Standard
Nonstandard
2
Building
Standard
Nonstandard
3
Building
Standard
Nonstandard
Building: Separate property supplemental application required.
Standard Open Lot: Open parking storage lots enclosed on all sides by a metal cyclone or equivalent fence not less than six feet
height or bounded on one or more sides by the wall or walls of a building, with no unprotected openings, and with the exposed sides
of lot enclosed by a metal cyclone or equivalent fence no less than six feet in height, with openings securely locked when
unattended.
e. Years in business: Years experience in this industry: Years ownership/management experience:
f. Provide complete details of all prior work experience:
g. Phone: Inspection Contact:
h. We
bsite Address:
i. What are your days and hours of operation?
j. Describe your business operations?
k. Are you engaged in any other operations?
Yes No
If yes, explain:
l. Do you conduct operations or have driving exposures in any state(s) other than where your garage operation is
domiciled? If yes, explain, including which state(s):
2. PRI
OR CARRIER / LOSS INFORMATION
a. During the past three (3) years, has any company ever cancelled, declined or refused to issue any similar
insurance to the applicant?
Yes No
If yes, explain:
b. Prior carriers for the last three (3) years. If no prior insurance, state “NONE”.
Carrier Name
Premium
Year 1
to
$
Year 2
to
$
Year 3
to
$
AG 59 19 01 18 Page 2 of 7
c. Prior loss information:
Date of
Loss
Description of Loss
Amount
Paid
Amount
Reserved
$
$
$
$
$
$
$
$
$
$
3. GENERAL UNDERWRITING INFORMATION
a. Do you loan, lease or rent vehicles to others?
Yes No
b. Do you engage in any rideshare programs?
Yes No
c. Do you own or sponsor a race car?
Yes No
d. Do you repossess:
(1) Autos that you have sold?
Yes No
(2) Autos for others?
Yes No
e. Any salvage/auto dismantling operations?
Yes No
If yes, separate supplemental application required.
f. Any animals kept on the premises?
Yes No
If yes, what breed(s) and purpose?:
g. Provide maximum radius for pickup and delivery:
(1)
Owned Autos: miles.
(2) Non-Owned/Customer’s Autos: miles. How many times per month?
h. How many plates do you have: Dealer: Transport/Transit: Other:
(1) Where are plates stored when not in use?
(2) Do you loan or rent plates?
Yes No
i. Describe your key control procedures:
(1) During business hours:
(2) After business hours:
j. Are firearms kept on the premises?
Yes No
k. Do you utilize sub-contractors?
Yes No
If yes: (1) Who and for what purpose?:
(2) Are certificates of insurance obtained from all?
Yes No
l. Do you attend or host trade shows, fairs, or any other special events?
Yes No
If yes, explain:
m. Percentage of operation (“X” all applicable operations below and show % of sales and/or % repair for each)
Type of Autos
Sales %
Repair %
ATVs, Snowmobiles*
Boats, Jet Skis or Other Watercraft
Buses: Type: Passenger Capacity:
Contractors/Construction Equipment*
Emergency Vehicles: Police Fire Ambulance
Farm Equipment
Golf Carts
Motorcycles, Scooters*
Motor Homes, Recreational Vehicles, Campers*
Private Passenger (including pickups, mini vans or SUVs)
Trailers: Semi-Trailers Utility Trailers Fifth Wheels Livestock
Trucks and/or Truck Tractors (other than pickups, mini vans or SUVs)*
Other (describe):
*Separate supplemental application required
AG 59 19 01 18 Page 3 of 7
4. DEALER INFORMATION “X” if no dealer operations exists
a. Are you a licensed dealer?
Yes No
Dealer ID #:
Non-Franchised Franchised with
Type:
Retail % Wholesale % Broker % Auction* %
*If Auction applies, separate supplemental application must be completed.
b. Do you sell autos on consignment? (If yes, copy of agreement required)
Yes No
If yes:
On your lot At other dealership locations
c. Estimate number of vehicles sold per year:
d. Do you engage in Internet Sales? Yes No
If yes: (1) Who is responsible for title transfer?
(2) How are vehicles transported?
e. Test drives:
(1) Do you allow customers to test drive vehicles unaccompanied?
Yes No
(2) Do you obtain a copy of their Driver License?
Yes No
(3) Do you obtain a copy of their proof of insurance?
Yes No
(4) Do you allow overnight test drives?
Yes No
f. Which of the following are used to transport or drive away vehicles from the places where they are purchased:
Employees Contract Drivers Transport Carrier Other:
g. Where do you purchase vehicles (provide %)?
Other dealers Auction Other
h. When are titles transferred? At time of sale When auto is paid in full
Other:
i. Do you require personal auto insurance to be in place prior to relinquishing a sold vehicle?
Yes No
j. If you finance autos for sale (Buy-here/Pay-here operation), are you listed as a lienholder?
Yes No
k. Value of owned (inventory) autos
Loc#
Average value
per auto
Maximum value
per auto
Average # of
autos
Maximum # of
autos
Maximum value of all
autos
1
2
3
AG 59 19 01 18 Page 4 of 7
5. NON-DEALER INFORMATION “X” if no service/non-dealer operations exists
Must equal 100%
Service/Repair
Percentage
Airbags
Alarm/Stereo Installation
Auto Parts New: % Used: % Uninstalled %
Body
Brakes
Breathalyzers/Ignition Interlock Devices
Car Wash Attended Unattended/Self-Serve
Detail Shop
Drive-away contractors
Engine
Frame Cutting Welding Stretching Straightening
Hydraulic Lifting apparatuses – Describe:
LPG (Liquefied Petroleum Gas)
Oil/Lube
Painting U/L approved booth Non-U/L approved booth*
Parking Facility: Public Valet**
Performance Enhancements (Beyond original manufacturer specs)
Service/Convenience Store** Gas Grocery Liquor
Storage/Impound Lot
Suspension Lift Kits Height:
Tires: New % Used % Recaps, Re-Treads, Split Rim Work
Trailer Hitch Installation Bolt-On Weld-On
Upholstery
Windshield Installation/Tinting
General Maintenance & Repair
Other (describe):
**Separate supplemental application required
a. Where are operations performed? (provide % for each that apply)
Your premises Customer Premises Roadside
Other:
b. Do you modify, rebuild or perform conversions on vehicles?
Yes No
If yes, explain:
c. Do you weld?
Yes No
(1) What do you weld?
(2) What protective safeguards are in place to prevent fire?
d. Are signs posted to keep customers from work areas?
Yes No
e. Do you manufacture or fabricate autos or auto parts?
Yes No
If yes, explain:
f. Do you offer expedited service (example: 30 min or less - quick lube)?
Yes No
g. Value of non-owned (customer) autos
Loc#
Average value
per auto
Maximum value
per auto
Average # of
autos
Maximum # of
autos
Maximum value of all
autos
1
2
3
AG 59 19 01 18 Page 5 of 7
6. OWNERS, EMPLOYEES AND DRIVERS INFORMATION
a. List all owners, employees, drivers and household members of driving age
(ALL employees, whether they drive or not & ALL household members, whether involved in garage operations or not):
First & Last Name
Driver’s License
Number / State
DOB
Accidents &
Violations
(within the
past 5 years)
Status*
(1–11)
Hours
Worked**
Furnished
(Personal
use)
Yes/No
Personal
Auto
Policy
Yes/No
Excluded
Driver
Yes/No
/
Yes
No
Yes
No
Yes
No
/
Yes
No
Yes
No
Yes
No
/
Yes
No
Yes
No
Yes
No
/
Yes
No
Yes
No
Yes
No
/
Yes
No
Yes
No
Yes
No
/
Yes
No
Yes
No
Yes
No
/
Yes
No
Yes
No
Yes
No
/
Yes
No
Yes
No
Yes
No
/
Yes
No
Yes
No
Yes
No
/
Yes
No
Yes
No
Yes
No
Do you utilize unscheduled (contract) drivers? Yes No
If yes: 1. Do you verify each has a valid US driver’s license?
Yes No
2. How many times per month?
*Status:
6
Mechanic
1
Active Owner, Partner or Officer
7
Clerical
2
Inactive Owner, Partner or Officer
8
Scheduled Driver
3
Salesperson
9
Spouse of Owner, Partner or Officer
4
Manager
10
Child of Owner, Partner or Officer (whether licensed to drive or not)
5
Lot Person
11
Other:
**Hours Worked:
F
Full Time (over 20 hours per week)
P
Part Time (20 hours or less per week)
N
Non-Employee
b. Have all individuals with access to use a covered auto been listed on this application Yes No
If no, explain:
AG 59 19 01 18 Page 6 of 7
7. COVERAGE REQUESTED
Provide limits and deductibles for all requested coverages:
COVERAGE
LIMITS
DEDUCTIBLES
Garage Liability
Each Accident
(Auto & Other Than Auto)
Aggregate
(Other Than Auto only)
$ PD
$ BI & PD
$
1x 2x 3x
Personal Injury Protection
$
$
Uninsured Motorists
Underinsured Motorists
$
$
Medical Payments
Auto & Premises
Premises Only
$
Errors & Omissions
Odometer Truth in Lending Title
Garagekeepers
Fire/Theft
Specified Causes
Comprehensive
Legal Direct Excess Direct Primary
Per Location Per Auto
Loc 1 $
$
$
Loc 2 $
Loc 3 $
Dealers Physical Damage
Fire/Theft
Specified Causes
Comprehensive
Per Location Per Auto
Loc 1 $
$
$
Loc 2 $
Loc 3 $
Loss Payee:
False Pretense
$
Broadened Coverage
Personal Injury Liability
Damage to Rented Premises $
Employment Practices
$
$
Additional Insured
Name:
Address:
Insurable Interest:
Landlord
Waiver of Subrogation
Other:
Optional Coverages not
listed:
Service vehicles, including tow trucks, car haulers and wreckers or specifically described autos:
Are filings required? Yes No If yes, list MC # and/or Certificate #:
Year
Make
Model
VIN/Serial #
MGVW
Use
Radius
In-Tow
1
$
Liability PIP UM/UIM Med Pay (Limits follow policy coverages)
Physical Damage - Limit: $ Deductible: $
Loss Payee:
2
$
Liability PIP UM/UIM Med Pay (Limits follow policy coverages)
Physical Damage - Limit: $ Deductible: $
Loss Payee:
3
$
Liability PIP UM/UIM Med Pay (Limits follow policy coverages)
Physical Damage - Limit: $ Deductible: $
Loss Payee:
AG 59 19 01 18 Page 7 of 7
The Applicant, Agent and/or Broker represents that the above statements and facts are true and that no material facts
have been suppressed or misstated.
Completion of this form does not bind coverage or commit the Company to policy issuance.
NOTICE TO APPLICANTS (EXCEPT CO & NY):
Any person who knowingly makes a claim containing false information or intentionally misrepresents any material
fact or knowingly presents false or misleading information in an application for insurance may be guilty of a crime
and subject to criminal and civil penalties.
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 policyholder or claimant for the purpose of defrauding or
attempting to defraud the policyholder or claiming with regard to a settlement or award payable for insurance
proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
NOTICE TO NEW YORK APPLICANTS:
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.
Applicant Name Applicant Signature Date
Producer Name Producer Signature Date
Producer Phone Number Producer Street Address
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Acceptance Indemnity Insurance Company Occidental Fire & Casualty (Risk Placement Services, Inc.)

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Completed 30 July 2020

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