Fillable GARAGE & AUTO DEALER Application ALL QUESTIONS MUST (Risk Placement Services, Inc.)

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GARAGE & AUTO DEALER Application ALL QUESTIONS MUST (Risk Placement Services, Inc.)

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1 of 5 CAG 7000 11/16
Broker Name: Retai
l Agent Name:
Broker Location:
Retail Agent Address:
Broker Contact:
Retail Agent Phone Number: ( ) -
Proposed effective date:
/ / to / /
Name of Applicant (include DBA)
Applicant is:
Mailing Address:
Contact: Phone Number: ( ) -
Website:
Number of years in business:
Number of years experience in this field:
Description of Operations:
Location #1
Location #2
Location #3
Yes
No
JOB DESCRIPTION OR RELATIONSHIP TO INSURED:
Owners, Partners, Officers, Salespersons, Managers. Inactive Owners, Inactive Partners, Inactive Officers.
Clerical staff, Lot personnel, Mechanics. Non-Employee - Spouse, Domestic Partner, Children.
Independent Contractors.
Contract Driver - provide name(s), or Blanket Contract Drivers.
PART TIME: Employees working less than 20 hours per week shall be considered Part Time.
APPLICANT INFORMATION
Furnished
an Auto for
to Insured
or Relationship
Drivers
Personal
of
#
Birth
or
Date
Part Time
or
Use?
ALL QUESTIONS MUST BE ANSWERED IN FULL, SIGNED AND DATED BY THE APPLICANT.
(see below)
Job Description
within the
Accidents
License
&
Violations
EMPLOYEE AND NON-EMPLOYEE INFORMATION
Full Time
State
Number
GARAGE & AUTO DEALER
Application
Loc.
Yes/ No
(see below)
Past 3 years
Have all owners, employees, non-employees, household members, independent contractors who
work for the business and drivers who may operate your vehicles or vehicles in your care, on a
regular or infrequent basis been disclosed above?
Individual
Joint Venture
Partnership LLC
Other Organizational Structure:
2 of 5 CAG 7000 11/16
Boats - Other Than Jet Skis*
% % Mobile Homes (non-motorized) % %
Busses*
% %
Motorcycles
*
% %
Bucket Trucks / Cranes / Scissor Lift*
% %
ATVs, UTVs, Scooters, Snowmobiles*
% %
Contractors Equipment*
% % Private Passenger, Light & Medium Truck % %
Emergency Vehicles*
% % Race Cars / Street Rods % %
Farm Equipment*
% % Recreational Vehicles, Motor Coaches % %
Public Livery / Transportation
% %
Semi Trailers*
% %
Golf Carts % % Trailers - Other than Semi Trailers % %
Heavy Truck (over 26,000 GVW)*
% %
Jet Skis*
% %
Kit Cars or Other Auto Manufacturing % %
Do you:
Engage in any other operations?
Yes
No Stack salvaged autos more than 2 high?
Yes
No
Engage in fuel conversion?
Yes
No
Work at airport, seaport or railroad premises?
Yes
No
Engage in performance enhancements?
Yes
No Engage in Breathalyzer / ignition interlock?
Yes
No
Loan, Lease or Rent autos to others?
Yes
No
Manufacture / Fabricate any auto parts?
Yes
No
Engage in auto pawning or auto title loans?
Yes
No
Yes
No
Dismantle autos or have salvage operations?
Yes
No
Own or operate a car crusher?
Yes
No
EXPLAIN ALL YES REPONSES:
Do you:
Secure all keys in a lock box or a secure cabinet away from vehicle?
Yes
No
Obtain certificates of insurance from all sub-contractors?
Yes
No N/A
Accompany customers in the service/repair area?
Yes
No N/A
Store all paints and solvents in a fire resistive cabinet outside the paint booth?
Yes
No N/A
Confine all spray painting operations to an UL approved booth?
Yes
No N/A
If No, is there explosion proof lighting and adequate ventilation?
Yes
No
Current Carrier Policy Period Policy Premium
Prior Carrier Policy Period Policy Premium
Prior Carrier Policy Period Policy Premium
Prior Carrier Policy Period Policy Premium
Prior Carrier Policy Period Policy Premium
If there is No Prior Insurance, check the box.
If there are No Prior Losses, check the box.
Any policy or coverage Declined, Cancelled or Non-Renewed during the prior Three (3) years?
Yes
No
(Missouri Applicants - Do not answer this question).
If yes, explain:
Dealers proceed to page 3, Non-Dealers proceed to page 4.
UNDERWRITING INFORMATION
OTHER (Provide complete description) :
%
*Supplemental application required
Sales
Sales
Repair
Driver involved
PRIOR INSURANCE COMPANY AND LOSS HISTORY
Repair
INDICATE PERCENTAGE OF THE FOLLOWING TYPE OF AUTOS SOLD / REPAIRED
Date of loss
Structurally alter or convert vehicles from their
original factory design?
Description of loss
%
3 of 5 CAG 7000 11/16
Non-Franchised Dealership
Reta
il: % Auction: %
New Auto/ Franchised Dealership
Internet: % Consigned: % (Provide copy of consignment agreement.)
Wholesale: %
Number of Dealer Plates
Plate numbers:
Do you Lease, Rent, Loan or Sell plates to others?
Yes No
If yes, explain:
How are plates are being used?
Where do you store plates when not in use?
Do you:
Obtain Drivers License and Proof of Insurance before all test drives?
Yes
No
Accompany all test drives?
Yes
No
Allow extended or overnight test drives?
Yes
No
Offer In-house financing or Buy Here / Pay Here?
Yes
No
If yes, are titles transferred to customer at the beginning of the finance period
and your business named as a lienholder?
Yes
No
Buy or sell autos in the following states? Check all that apply.
Covered Autos Liability Each Accident
General Liability BI & PD
Each Accident
Symbol 22 & 29
Damage to Premises Rented
Any One Premises
or Personal & Advertising Injury Any One Person or Organization
Symbol 21 General Liability Aggregate Limit
Products & Work Performed Aggregate Limit
Loc & Operations Medical Payments
Any One person
Auto Medical Payments
Any One person
Hired Auto
Broad Form Products
Assault & Battery Buyback
Personal Injury Protection:
Limit per Statute
Uninsured Motorists Coverage Each Acc.
Underinsured Motorists Coverage Each Acc.
Uninsured Motorists Property Damage Each Acc.
Owned Auto Coverage:
Limit Location 1 Maximum Limit Per Auto
Limit Location 2
Comprehensive Limit Location 3 Deductible Per Auto
Specified Causes Vehicle storage:
Building
Standard Lot*
Non-Standard Lot* Unprotected Lot*
Collision Theft Buyback, for Unprotected Lot.
(subject to guidelines) False Pretense
Types of Autos:
New Autos Used Autos, Demonstrators, Service Vehicles
Interest(s) Covered (Check all that apply):
Your interest in covered autos you own Your interest only in financed autos
Your interest & interest of any creditor/ loss payee Consigned Auto
Creditor/Loss Payee:
Name:
Address:
Title E&O Federal Odometer E&O Truth In Lending E&O Insurance Agents E&O
Dealer's Acts,
Errors & Omissions:
*Standard Lot: During non-operating business hours all entrances, exits, or openings and the entire perimeter is
surrounded by fences with gates or heavy chains and locks.
*Non-Standard Lot: Any other type of protection.
DEALER OPERATIONS
Auto Dealers Liability
Buy
Kansas
Kentucky
Dealers Physical Damage
State
*Unprotected Lot: No theft barrier.
Minnesota
Maryland
Michigan
South Carolina
Radius of pickup & delivery
Sell
Sell
Number of times per year
New Jersey
State
Buy
Number of times per year
North Dakota
New York
same as above
DEALERS COVERAGES & LIMITS
Deductible
Symbol 31
0 - 300 Miles
501 - 1,000 Miles
Unlimited 301 - 500 Miles
4 of 5 CAG 7000 11/16
Alarm, Stereo or Navigational System
% Handicap Vehicle Modification %
Auto Detailing (other-than car wash - full service)
%
Impound Yards
%
Auto Dismantling / Salvage Yard Lift Kit/ Lower Kit Installation, Service or Repair %
Payroll:
%
Mobile Auto Repair / Roadside Assistance
%
Auto Maintenance or Repair Incl Bed liner % Mobile Tire Sales, Installation, Service or Repair %
Auto Part Sales - New Parts Only (Uninstalled)
Oil/Lube Service %
Receipts: %
Parking Lots & Garages - self park only
*
%
Auto Part Sales- Used Parts Only (Uninstalled)
Rim Repair %
Receipts:
%
Storage Lots %
Body & Paint Shop % Tire Sales, Installation, Service or Repair %
Butane, Propane or other Liquefied Gas Sales
%
Trailer Hitch Installation or Repair
%
Car Wash - Full Service % Upholstery %
Convenience Store
Receipts:
% Valet Parking
*
%
Driveaway Contractor % Van Conversion %
Frame or Unibody Straightening
%
Welding:
Structural
Non-Structural %
Repair Modification Window Tinting %
Gasoline Station: Full Service % Windshield Installation/Repair %
Gasoline Station: Self Service only % Wrecker Service: For-Hire %
Convenience Store Receipts: Wrecker Service: Not-For-Hire %
Other:
%
Auto Only Each Accident
Other Than Auto
same as above
Each Accident
Other Than Auto Aggregate Limit
Personal Injury Liability
Broadened Coverage (includes Personal Injury & $100,000 Damage to Rented Premises)
Damage to Rented Premises Any One Premises
Loc & Operations Medical Payments
Any One person
Auto Medical Payments
Any One person
Hired Auto Broad Form Products
Assault & Battery Buyback Liquor Liability Buyback
Registration / Repairer / Transporter Plates
# of Plates:
Plate Numbers:
Personal Injury Protection Limit Per Statute
Uninsured Motorists Coverage Each Acc.
Underinsured Motorists Coverage Each Acc.
Uninsured Motorists Property Damage Each Acc.
Limit Location 1 Maximum Limit Per Auto
Limit Location 2
Limit Location 3 Deductible Per Auto
Specified Causes
Comprehensive Vehicle storage:
Building
Standard Lot* Non-Standard Lot* Unprotected Lot*
Collision
Theft Buyback, for Unprotected Lot
(subject to guidelines)
Legal Liability
Direct Excess
Direct Primary
*Unprotected Lot: No theft barrier.
Garagekeepers
NON-DEALERS / SERVICE OPERATIONS
Radius of pickup & delivery
Non-Dealer Liability
Deductible
*Supplemental application required
Symbol 29
*Standard Lot: During non-operating business hours all entrances, exits, or openings and the entire perimeter
is surrounded by fences with gates or heavy chains and locks.
*Non-Standard Lot: Any other type of protection.
Symbol 30
NON-DEALER COVERAGES & LIMITS
0 - 25 Miles
101 - 200 Miles
26 - 100 Miles Over 200 Miles
5 of 5 CAG 7000 11/16
Lessor of Leased Equipment (CA 2047)
Grantor of Franchise (CA 2049)
Owner of Garage Premises (CA 2509)
Designated Person or Organization (CAG 1712 / CAG 1912)
Scheduled Person or Organization Primary and Non-Contributory (CAG 1752 / CAG 1952)
Waiver of Subrogation (CA 0444)
Name:
Address:
Relationship to Insured:
Applies to location: # 1 # 2 # 3
How do you transport autos?
Driven by:
Employee
Temporary / Contract Driver
Towed by:
Employee
Temporary / Contract Driver Third party Tow Truck or Car Hauler
Certificate of Insurance on file?
Yes
No
Do you:
Repossess vehicles for others?
Yes
No
Require a Federal Filing?
Yes
No
Tow, Haul or Carry more than 2 autos at once?
Yes
No
Tow For-Hire?
Yes
No
If yes, is In-Tow Coverage required?
Number of Tow Trucks:
Towing exposure: The vehicle, trailer, tow bar, or tow dolly must be specifically scheduled on the policy.
Coverage: (check all that apply)
Liability Specified Causes
Uninsured/Underinsured Comprehensive
Personal Injury Protection Collision
Year: Year:
Make & Model: Make & Model:
VIN: GVW: VIN: GVW:
Radius of Operation:
Miles
Radius of Operation:
Miles
Stated Value: $ Stated Value: $
Is vehicle titled to the Named Insured?
Yes
No Is vehicle titled to the Named Insured?
Yes
No
Lessor - Additional Insured & Loss Payee Lessor - Additional Insured & Loss Payee
Name: Name:
Address: Address:
Check all that apply: Check all that apply:
Service Use
Towing Not For-Hire
Service Use
Towing Not For-Hire
Personal Use Towing For-Hire Personal Use Towing For-Hire
Rental / Loaner Trailer, Tow Dolly or Car Hauler Rental / Loaner Trailer, Tow Dolly or Car Hauler
ADDITIONAL INFORMATION
Witness
Applicant's Signature
Date
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.
Applicable in NY: Any person who knowingly and with the 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 throusand dollars and the stated value of the claim for each such violation.
ADDITIONAL INSUREDS
AUTO TRANSPORT / TOWING
Available in AL, CA, MS, MO, NM, OH, SD, TN, TX, VA, WA, WY.
SCHEDULED AUTO LIABILITY OR PHYSICAL DAMAGE COVERAGE (Symbol 27)
ADDITIONAL INSURED / WAIVER OF SUBROGATION INFORMATION
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GARAGE & AUTO DEALER Application ALL QUESTIONS MUST (Risk Placement Services, Inc.)

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Completed 30 July 2020

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