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GARAGE AND DEALERS SECTION (Graham-Rogers Insurance)

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© 1991-2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
Page 1 of 3
GARAGE AND DEALERS SECTION
POLICY NUMBER
NAIC CODE
CARRIER
AGENCY NAMED INSURED(S)
AGENCY CUSTOMER ID:
DATE (MM/DD/YYYY)
NUMBER OF GALLONS OF GAS PUMPED PER YEAR:ANNUAL GROSS SALES $
SERVICE OR REPAIR SHOPS
COVERAGES / LIMITS
USE ACORD 138 FOR YOUR STATE TO PROVIDE COVERAGES / LIMITS INFORMATION
NON-DEALERS PREMISES & OPERATIONS
# EMPLOYEES
ANNUAL REMUNERATION
ESTIMATED
#
LOC
$
$
$
DEALERS PHYSICAL DAMAGE
COVERAGE NEW
YOUR INTEREST IN
COVERED AUTOS
YOU OWN
YOUR INTEREST ONLY
IN FINANCED
COVERED AUTOS
YOURS AND FINANCED
INTERESTS IN
COVERED AUTOS
USED
COMPREHENSIVE
SPECIFIED PERILS
COLLISION
USE
%
VEH #
USE
HIRE
DATE
LIC
STATE
SOCIAL SECURITY NUMBER
DRIVERS LICENSE NUMBER/
LIC
YEAR
EXP
YRS
DATE OF BIRTH
STAT
MAR
SEXNAME (Include address, if required)
#
DRIVER
LIST ALL DRIVERS, INCLUDING FAMILY MEMBERS THAT WILL DRIVE COMPANY VEHICLES, AND EMPLOYEES WHO DRIVE OWN VEHICLES ON COMPANY BUSINESS.
ACORD 163 attached for additional driversDRIVER INFORMATION
THE NUMBER OF WEEKS WORKED ARE TO BE COUNTED AS 1/2 RATING UNIT.
2. PART-TIME EMPLOYEES WORKING AN AVERAGE OF LESS THAN 20 HOURS A WEEK FOR
THE NUMBER OF WEEKS WORKED ARE TO BE COUNTED AS 1 RATING UNIT EACH.
NOTE: 1. PART-TIME EMPLOYEES WORKING AN AVERAGE OF 20 HOURS OR MORE A WEEK FOR
RELATIVES OF ANY PERSON DESCRIBED IN CLASS I.
AUTO: INACTIVE-PROPRIETORS, PARTNERS OR OFFICERS AND THEIR RELATIVES AND THE
ANY OF THE FOLLOWING PERSONS WHO ARE REGULARLY FURNISHED WITH A COVERED
CLASS II - NON-EMPLOYEES
ALL OTHERS - ALL OTHER EMPLOYEES
FURNISHED A COVERED AUTO.
WHOSE PRINCIPAL DUTY INVOLVES THE OPERATION OF COVERED AUTOS OR WHO IS
OPERATION, SALESPERSONS, GENERAL MANAGERS, SERVICE MANAGERS; ANY EMPLOYEE
REGULAR OPERATOR - PROPRIETORS, PARTNERS AND OFFICERS ACTIVE IN THE GARAGE
CLASS I - EMPLOYEES
DEFINITIONS:
BY LOCATION NUMBER
CLASS OF OPERATORS
CLASS I REGULAR OPERATORS
EMPLOYEES ALL OTHERS
CLASS II UNDER AGE 25
NON-
EMPLOYEES
ALL OTHERS
AUTO DEALERS OPERATORS
BUSINESS / VEHICLE STORAGE INFORMATION
%
%
%
%
%
%
%
%
%
%
%
%
VEHICLE STORAGE
TYPE OF FACILITY LOCATION #
BUILDING
STANDARD OPEN LOT
NON-STANDARD OPEN LOT
AUTO SERVICE OPERATIONS OR
TRAILER SALES
STORAGE/GARAGE/PUBLIC PARKING
COMMERCIAL TRAILER DEALER
SERVICE STATION
MOBILE HOME TRAILER DEALER
REPAIR SHOP
%
%
%
%
%
%
SNOWMOBILE
RECREATIONAL VEHICLE
MOTORCYCLE
TRUCK-TRACTOR
CAR
NON-FRANCHISEDFRANCHISED
AUTO DEALERS
ACORD 128 (2008/05)
Page 2 of 3
AGENCY CUSTOMER ID:
Y / N
EXPLAIN ALL "YES" RESPONSES
1. A speeding violation of up to six (6) mph that occurs in an area with a maximum posted speed limit from 30 mph through 54 mph, or
2. A speeding violation of up to ten (10) mph that occurs in an area with a maximum posted speed limit from 55 mph through 70 mph.
APPLICABLE ONLY IN KANSAS: UNDER KANSAS LAW, THE FOLLOWING TRAFFIC VIOLATIONS ARE NOT REQUIRED TO BE REPORTED TO INSURERS:
18. ANY DRIVERS WITH CONVICTIONS FOR MOVING TRAFFIC VIOLATIONS?
GENERAL INFORMATION
1. DOES APPLICANT RENT, LEASE OR LOAN VEHICLES TO OTHERS?
2. DOES APPLICANT PICK-UP OR DELIVER CUSTOMER'S CARS?
3. DOES PICK-UP OR DELIVERY EXCEED 50 MILES?
4.
IS TIRE RECAPPING OR RETREADING PERFORMED?
5. DOES APPLICANT OWN OR SPONSOR A CAR FOR RACING?
6. DOES APPLICANT HANDLE BUTANE, PROPANE OR OTHER GASES?
7. ARE VEHICLES FURNISHED FOR GROUP OR ORGANIZATIONS?
8. DOES APPLICANT PERFORM SPRAY PAINTING OR WELDING?
10. DOES APPLICANT DISMANTLE AUTOS OR HAVE SALVAGE OPERATION?
11. DOES APPLICANT USE TOW TRUCKS?
12. DO EMPLOYEES REGULARLY USE OWN AUTOS ON COMPANY BUSINESS?
9. DOES APPLICANT DRIVE-AWAY OR HAUL-AWAY VEHICLES FROM FACTORY DISTRIBUTING POINT OR OTHER DEALERS?
13. DOES APPLICANT PARK CUSTOMER'S VEHICLES ON PUBLIC STREETS OR OFF PREMISES?
14. IS A CHARGE MADE FOR PARKING? (Give locations, # attendants)
15. ANY PRIVATE PROTECTION SYSTEMS? (fences, dogs, alarms, guards)
16. IS APPLICANT INVOLVED IN ANY "NON GARAGE" OPERATIONS? (Mini Marts, Liquor Stores, etc)
17. DOES APPLICANT PERFORM ROAD EMERGENCY SERVICES?
ACORD 128 (2008/05)
ACORD 128 (2008/05) Page 3 of 3
ADDITIONAL INTEREST / CERTIFICATE RECIPIENT ACORD 45 attached for additional names
INTEREST RANK: NAME AND ADDRESS REFERENCE #: CERTIFICATE REQUIRED INTEREST IN ITEM NUMBER
ADDITIONAL INSURED
LOSS PAYEE
LIENHOLDER
EMPLOYEE AS LESSOR
VEHICLE:
SCHEDULED ITEM NUMBER:
OTHER
ITEM DESCRIPTION:
INTEREST RANK: NAME AND ADDRESS REFERENCE #: CERTIFICATE REQUIRED INTEREST IN ITEM NUMBER
ADDITIONAL INSURED
LOSS PAYEE
LIENHOLDER
EMPLOYEE AS LESSOR
VEHICLE:
SCHEDULED ITEM NUMBER:
OTHER
ITEM DESCRIPTION:
INTEREST RANK: NAME AND ADDRESS REFERENCE #: CERTIFICATE REQUIRED INTEREST IN ITEM NUMBER
ADDITIONAL INSURED
LOSS PAYEE
LIENHOLDER
EMPLOYEE AS LESSOR
VEHICLE:
SCHEDULED ITEM NUMBER:
OTHER
ITEM DESCRIPTION:
INTEREST RANK: NAME AND ADDRESS REFERENCE #: CERTIFICATE REQUIRED INTEREST IN ITEM NUMBER
ADDITIONAL INSURED
LOSS PAYEE
LIENHOLDER
EMPLOYEE AS LESSOR
VEHICLE:
SCHEDULED ITEM NUMBER:
OTHER
ITEM DESCRIPTION:
REMARKS
AGENCY CUSTOMER ID:
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GARAGE AND DEALERS SECTION (Graham-Rogers Insurance)

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Completed 8 January 2021

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