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GARAGE APPLICATION ALL QUESTIONS MUST BE ANSWERED IN (Risk Placement Services, Inc.)

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Broker #: Retailer:
Broker: Location:
Location:
Phone #:
Applicant Name
Mailing Address
Proposed Policy Period to
Location #1
Location #2
Individual Partnership Joint Venture Corporation Other
Insured's Website Address
Inspection and Audit Contact / Phone Number
Years in business Years of experience in this field
NATURE OF BUSINESS
DEALER: Franchised Non-Franchised
Please Indicate Percent: Consigned Autos Held for Sale Owned Autos Held for Sale
Auto Auctions Wholesale Autos
Other (describe)
NON-DEALER: Repair Shop Gas Station Parking Facility Other
UNDERWRITING INFORMATION
DO YOU: YES NO YES NO
1. Engage in any other operations? 6. Repossess vehicles for others?
2. Sponsor sporting or social events? 7. Engage in fuel conversion?
3. Sponsor or own any race cars? 8. Engage in auto pawning?
4. Work on aircraft or airport premises? 9. Allow customers in the work area?
5. Structurally alter or convert vehicles 10. Own or operate a car crusher or stack
from their original design? salvaged autos more than two high?
EXPLAIN ALL "YES" RESPONSES:
ALL QUESTIONS MUST BE ANSWERED IN FULL, SIGNED AND DATED BY THE APPLICANT.
GARAGE APPLICATION
Page 1 of 4 09/01/07 ed.
Sales Repair
Private Passenger Type Including Light & Medium Trucks - New % %
Private Passenger Type Including Light & Medium Trucks - Used % %
Antique/Classic Cars %%
Boats - Other Than Jet Skis % %
Jet Skis %%
Buses %%
Contractors Equipment **include complete list of equipment** %%
Farm Equipment %%
Emergency or Public Livery % %
Heavy Truck (over 26,000 GVW) **supplement required** %%
Kit Cars or Other Auto Manufacturing % %
Motorcycles, ATVs, Scooters, Snowmobiles **supplement required** %%
Mobile Homes %%
Recreational Vehicles and Campers **supplement required** %%
Semi Trailers %%
Trailers - Other than Semi Trailers % %
TOTAL
Alarm, Stereo or Navigational System % Gasoline Station - Self Service %
Auto Dismantling % Impound Yards
Auto Maintenance or Repair Incl Bedliner % Mobile Auto Repair %
Auto Painting with UL approved spray booth % Oil/Lube Service %
Auto Painting without UL approved spray booth % Parking Lots & Garages (self park) %
Auto Parts (uninstalled) Receipts:
% Tire Dealers - New %
Body Shop % Tire Dealers - Used, Retreads or Split Rims %
Butane, Propane or other Liquefied Gas Sales % Trailer Hitch Installation or Repair %
Car Wash - Full Service % Upholstery %
Convenience Store Receipts:
% Valet Parking **supplement required** %
Detailing % Van Conversion %
Driveaway Contractor or Wrecker Service % Window Tinting %
Frame or Unibody Straightening % Windshield Installation/Repair %
Gasoline Station - Full Service % Other: %
How are vehicles stored? How are vehicles stored?
Standard Lot* Building Standard Lot* Building
Non-Standard Lot* Unprotected Lot Non-Standard Lot* Unprotected Lot
Maximum value any one Auto? Maximum value any one Auto?
Maximum number of Autos? Maximum number of Autos?
*Standard Lot: Standard open lots are open parking storage lots enclosed on all sides by a metal cyclone or equivalent fence not less than six feet
in 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 the lot
enclosed by a metal cyclone or equivalent fence not less than six feet in height, with openings securely locked when unattended. Non-Standard L
o
Any other type of protection or fencing. Unprotected Lots: All Other
VEHICLE STORAGE & VALUES
Owned Autos Non-Owned Autos
PLEASE INDICATE PERCENTAGE OF THE FOLLOWING TYPE OF AUTOS YOU ARE INVOLVED IN
NON-DEALERS OPERATIONS
100%
Page 2 of 4 09/01/07 ed.
EMPLOYEE AND NON-EMPLOYEE INFORMATION
YOU MUST COMPLETE THE FOLLOWING INFORMATION FOR
ALL EMPLOYEES, DRIVERS AND HOUSEHOLD MEMBERS
Name and Driver's Date of Violations & Accidents Hours Auto
License # & State Birth Prior Three Years Worked Use
STATUS: 1. Active Owner, Partner or Officer 7. Spouse of Owner, Partner or Officer
2. Inactive Owner, Partner or Officer 8. Children of Owner, Partner or Officer
3. Salesperson 9. Spouse of any other person furnished an auto
4. Lot Person 10. Children of any other person furnished an auto
5. Mechanic 11. Occasional or Contract Driver
6. Clerical 12. Other
HOURS WORKED: AUTO USE:
F = Full Time (Over 20 hours per week) A = Furnished a covered auto for personal use
P = Part Time (20 or less hours per week) B = Uses a covered auto strictly for business use
N = Non-Employee C = Does not drive a covered auto
Current Carrier
Prior Carrier
Prior Carrier
If there is no prior insurance, check the box.
If there are no prior losses, check the box.
THREE-YEAR PRIOR CARRIER AND LOSS HISTORY
Status
Policy Premium
Date of loss Amount paid/reserve Description of loss including driver
Policy Period Policy Premium
Policy Period
Policy Period
Policy Premium
Page 3 of 4 09/01/07 ed.
Auto Each Accident BI
Other Than Auto Each Accident PD
Other Than Auto Aggregate Limit
Deductible
Comprehensive Specified Limit Per Location Other Than Collision
Collision Limit Per Auto Collision
False Pretense
Legal Liability Limit Per Location Other Than Collision
Direct Excess Limit Per Auto Collision
Direct Primary
Comprehensive Specified In-Tow Coverage For-Hire Not-For-Hire
Collision Limit Per Tow Truck # of Tow Trucks
Auto Garage Operations
Broadened Coverage
(includes Personal Injury & $50,000 Fire Legal)
Hired Auto
Fire Legal Liability Limit Broad Form Products
Personal Injury Liability
Additional Insured Name
Address
Waiver of Subrogation Insurable Interest
Each Accident Number of Dealer Tags:
Each Accident
Per Statute
Radius of Pickup & Delivery: None 0-300 Miles 301-500 Miles 501-1000 Miles +1000 Miles
Dealer's Errors & Omissions: Title E&O Truth In Lending E&O
Federal Odometer E&O Insurance Agents E&O
Scheduled Auto Liability or Physical Damage: Complete the Scheduled Auto Supplement
NOTICE: The policy of insurance applied for does not provide coverage as required by Environmental Protection Agency (EPA) 40 CFR Parts
280 and 281 for underground storage tanks nor coverage under CERLA or similar state or federal environmental act(s). THIS POLICY EXCLUDES
ALL COVERAGE FOR POLLUTION. Any person who knowingly and with intent to defraud the Company filing an application for insurance
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. This application shall not be binding unless and until confirmation by the Company or its duly
appointed representatives has been given, and that a policy shall be issued and a payment shall be made, and then only as of the
commencement date of said policy and in accordance with all terms thereof. The said applicant hereby covenants and agrees that the foregoing
statements and answers are a full and true statement of all the facts and circumstances with regard to the risk to be insured, and the same are
hereby made the basis and conditions of the insurance and a warranty on the part of the insured.
Deductible
ADDITIONAL INFORMATION
DeductibleLimit of Liability
COVERAGES & LIMITS
Medical Payments
Personal Injury Protection
Uninsured Motorists Coverage
Underinsured Motorists Coverage
Garagekeepers Limit of Coverage
Dealers Open Lot Limit of Coverage
Witness Date
Garage Liability
Applicant's Signature
Page 4 of 4 09/01/07 ed.
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GARAGE APPLICATION ALL QUESTIONS MUST BE ANSWERED IN (Risk Placement Services, Inc.)

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Completed 30 July 2020

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