Page 1 of 5 01/01/18 ed.
Proposed Effective Date: Producer: Name
Proposed Expiration Date: Address
Phone #
Individual
Partnership
Corporation
Joint Venture
Contact & Email: Limited Liability Corp.
Years in Business: Years of Experience:
Locations: Same as above
1
2
3
4
No Prior Carrier No Prior Losses
Furnished an Auto for Personal Use Not Furnished an Auto for Personal Use
Class A - principal or employee Class D - any individual whose primary duty
Class B - non-employees without a personal auto policy in place involves operation of covered autos
Class C - non-employees with a personal auto policy in place Class E - mechanics or lot persons
Class F - clerical or sales counter duties
EMPLOYEE INFORMATION
Full Name and
Driver's
FT or
Class (See
Moving Violations
Date of Birth
License #
PT
Below)
(past 3 years)
PRIOR CARRIER AND LOSS INFORMATION
Prior Carrier
Policy Yr
Description of Loss
Amount Paid
Amount Reserved
Business Phone:
Website Address:
GARAGE AND AUTO DEALERS
APPLICATION
Page 2 of 5 01/01/18 ed.
%
Antique or Classic Auto Dealer
%
Golf Cart Dealer
%
ATV, UTV, Dirt Bike or Snowmobile Dealer
%
Heavy Truck Dealer
%
Auto Auction
%
Logging Equipment Dealer
%
Auto Dealer - PPV and Light/Medium Truck
%
Motorcycle Dealer
%
Boat or Jet Ski Dealer
%
RV Dealer
%
Bus Dealer
%
Salvage Titled Autos
%
Camper or Travel Trailer Dealer
%
Semi Trailer Dealer
%
Contractor's Equipment Dealer
%
Tank or Tank Truck Dealer
%
Emergency Vehicle Dealer
%
Trailer Dealer - Utility/Livestock
%
Farm Equipment Dealer
%
Wholesale Auto Dealer
%
Valet Parking - Designated Locations -
%
Impound Yard
No Street Driving or Parking %
Parking Facilities - No Valet
%
Valet Parking - Designated Locations -
%
RV Storage
Including Street Driving or Parking
%
Valet Parking - Blanket Basis - Including Special Events
%
Airbag Installation or Repair
%
Golf Cart Repair
%
Alarm Installation or Repair
%
GPS Installation
%
Antique or Classic Auto Repair
%
Heavy Truck Repair
%
ATV, UTV, Dirt Bike or Snowmobile Repair
%
High Performance Shop
%
Auto Dismantling
%
Ignition Interlock
%
Auto Maintenance and Repair
%
Inspection Station
%
Auto Parts and Accessory Sales
%
Lift Kit Installation
%
Auto Pawning
%
Machine Shop
%
Bedliner Installation
%
Manufacturing or Assembly
%
Boat or Jet Ski Repair
%
Mobile Auto Repair
%
Body Shop & Painting with UL Approved Booth
%
Motorcycle Repair
%
Body Shop & Painting without UL Approved Booth
%
Oil/Lube Shop
Explosion Proof Lighting/Adequate Ventilation Present?
%
Refrigeration Unit Servicing
%
Brake Replacement or Repair
%
Rental or Leasing Operations
%
Bus Repair
%
Repossession - For-Hire
%
Camper or Travel Trailer Repair
%
RV Repair
%
Car Wash - Full Service
%
Salvage Yard
%
Car Wash - Self Service
%
Semi Trailer Repair
%
Contractor's Equipment Repair
%
Stereo Installation
%
Convenience Store
%
Tank or Tank Truck Repair
%
Conversion Shop
%
Trailer Repair - Utility/Livestock
%
Detailer
%
Tire Dealer or Repair
%
Drive-Away Contractor
%
Upholstery
%
Emergency Vehicle Repair
%
Window Tinting
%
Farm Equipment Repair
%
Windshield Replacement/Repair
%
Frame Straightening
%
Wrapping of Autos
%
Frame Cutting, Stretching, Shortening
%
Wrecker For-Hire
%
Gasoline Station - Full Service
%
Wrecker Not-For-Hire
%
Gasoline Station - Self Service
%
NATURE OF BUSINESS (INDICATE PERCENTAGE OF EACH)
Total of all percentages on this page should equal 100%
SALES
PARKING AND STORAGE
SERVICE OR REPAIR
Atlantic Casualty Garage Application
Page 3 of 5 01/01/18 ed.
Symbol(s): 21 - Any Auto Deductible:
22 - Any Owned Auto
28 - Hired Autos Pickup & Delivery Distance: 0-200 Miles
29 - Non-Owned Autos
Over 200 Miles
Covered Autos Liability
Limit Each Accident
General Liability - Bodily Injury & Property Damage Limit Each Accident
Damage to Premises Rented to You Limit Any One Premises
Personal & Advertising Injury Liability Any One Person or Organization
General Liability Aggregate
Products & Work You Performed Aggregate
Coverage: Specified Causes Legal Liability Deductible:
Comprehensive Direct Excess
Collision Direct Primary
Lot Limit: Per Vehicle Limit:
Coverage: Specified Causes Building
Comprehensive Standard Lot (6' metal cyclone or equivalent fence)
Collision Non-Standard Lot (fencing other than standard)
False Pretense Unprotected (no fencing)
Deductible:
Lot Limit: Per Vehicle Limit:
Uninsured Motorists Limit:
Underinsured Motorists Limit:
Personal Injury Protection Limit:
Virginia Medical Expense & Income Loss Limit:
Locations & Operations Medical Payments Auto Dealers Acts, Errors or Omissions
Limit Per Person: Truth in Lending
Auto Medical Payments Odometer
Limit Per Person: Insurance Agents or Brokers
Broad Form Products Title
Drive Other Car
LIABILITY COVERAGE
Coverage Basis:
GARAGEKEEPERS COVERAGE
OPTIONAL COVERAGES
UNINSURED, UNDERINSURED AND PERSONAL INJURY PROTECTION
DEALER'S PHYSICAL DAMAGE COVERAGE
Lot Protection:
Number of
Dealer Plates
Atlantic Casualty Garage Application
Page 4 of 5 01/01/18 ed.
Additional Insured - Owner of Leased or Rented Land or Premises
Lessor - Additional Insured and Loss Payee (AGP-016)
Additional Insured - Lessor of Leased Equipment (AGP-019)
Additional Insured - Grantor of Franchise (AGP-020)
Designated Insured (AGP-018) - Describe Interest
Waiver of Transfer of Rights of Recovery Against Others to Us (AGP-035)
Primary and Noncontributory (AGP-007)
Coverage(s): Liability Specified Causes Comprehensive Collision
Physical Damage Deductible:
VIN
Do you have any Liquefied Petroleum Gas (LPG) exposures in your operations?
If yes, do you abide by the NFPA 58 - Liquefied Petroleum Gas Code?
Comments:
Year/Make/Model
Used for
Towing (Y/N)
Vehicle Value
GVW
SCHEDULED AUTOS
ADDITIONAL INSURED OPTIONS
Atlantic Casualty Garage Application
Page 5 of 5 01/01/18 ed.
FRAUD WARNING:
PRODUCER'S SIGNATURE DATE
APPLICANT'S SIGNATURE DATE
Any person who knowingly and with intent to defraud any insurance company or other person files 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 and subjects that person to
criminal and civil penalties (In Oregon, the aforementioned actions may constitute a fraudulent insurance act which
may be a crime and may subject the personal to penalties). (In New York, the civil penalty is not to exceed five
thousand dollars ($5,000) and the stated value of the claim for each such violation). (Not applicable in AL, AR, AZ,
CO, DC, FL, KS, LA, ME, MD, MN, NM, OK, PR, RI, TN, VA, VT, WA & WY).
Applicable in AL, AR, AZ, DC, LA, MD, NM, RI & WV: Any person who knowingly (or willfully in MD) presents a false
or fraudulent claim for payment of a loss or benefit or who knowingly (or willfully in MD) presents false information
in an application for insurance is guilty of a crime and may be subject to fines or confinement in prison.
Applicable in Colorado: 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 or 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 claimant with regard to a settlement or
award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the
department of regulatory agencies.
Applicable in Florida and Oklahoma: Any person who knowingly and with intent to injure, defraud, or deceive any
insurer files a statement of claim or an application containing false, incomplete, or misleading information is guilty of
a felony (In FL, a person is guilty of a felony of the third degree).
Applicable in Kansas: 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 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 conceals, for the purpose of misleading, information concerning
any fact material thereto commits a fraudulent insurance act.
THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE
INQUIRY HAS BEEN MADE TO OBTAIN THE ANSWERS TO QUESTIONS ON THIS APPLICATION. HE/SHE REPRESENTS
THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HER KNOWLEDGE.
Applicable in Maine, 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. Penalties may include
imprisonment, fines or denial of insurance benefits.
Atlantic Casualty Garage Application
click to sign
signature
click to edit
click to sign
signature
click to edit
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome