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Garage Application
FEIN#: ____________________________________________________
Applicant name: ____________________________________________________________________________________________________
Doing business as (DBA): ____________________________________________________________________________________________
Mailing address: ____________________________________________________________________________________________________
City: ______________________________________________________ State: _________________ Zip Code: ___________________
Website address: __________________________________________
Contact name: __________________________________________ Contact phone number: _______________________________
Effective date: ____________________________________________ Expiration date: ________________________________________
Years in business: ____________________________________________
If less than 3 years, please provide industry experience:
Lines of business
Property
Garage/Auto
Workers’ Comp
EPLI
Umbrella
Other
Legal status
Individual
Partnership
Corporation
LLC
Other
Description of operations
Franchise auto dealer
Non-franchise auto dealer
Non-dealer (describe below)
General Information
General Rating Information
Page 1 of 7
Coverage Symbols Limits / Deductibles
Liability
21
22
23
24
27
28
29
32
Each accident limit
Aggregate limit
Deductible
$ ______________
$ ______________
$ ______________
PIP
25
27
Added PIP
25
27
Medical
22
23
24
27
32
$ ______________
Uninsured
22
26
27
$ ______________
Underinsured
22
26
27
$ ______________
Garagekeepers
Specied perils
Comprehensive
Collision
30
32
Per auto deductible
Per occurrence deductible
$ ______________
$ ______________
Physical damage
Specied perils
Comprehensive
Collision
27
28
31
32
Per auto deductible
Per occurrence deductible
$ ______________
$ ______________
Towing & labor
23
27
Page 2 of 7
Misc. Coverage Information
Location Information
Coverage Desired Limits Valuation / Deductible
EPLI
$ _______________________ Deductible $ ______________
Umbrella
$ _______________________ $10,000 SIR mandatory
Other: _____________________________________
_________________________ __________________________________________
Location #1
Same as mailing address
Other, see below
Address: __________________________________________________________________________________________________________
City: _______________________________________________________ State: _________________ Zip code: ___________________
Garagekeepers:
Garagekeepers limit per location: _________________________________
Maximum limit per auto: __________________________________
Specied perils
Comprehensive
Collision
Direct primary
Direct excess
Legal liability
Are vehicles stored overnight?
Yes
No Lot protection:
Building
Fenced
Unprotected
Comprehensive deductible:
$100/$500
$250/$1,000
$500/$2,500
$1,000/$5,000
$2,500/$12,500
$5,000/$25,000
Collision deductible:
$100
$250
$500
$1,000
$2,500
$5,000
Dealers open lot:
Dealers open lot limit per location: ________________________________
Maximum limit per auto: __________________________________
Specied perils
Comprehensive
Collision
Standard open lot
Non-standard open lot
Building
Standard open lot: Open parking or storage lots enclosed on all sides by a metal cyclone 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 opening and with exposed sides of the lot
enclosed by a metal cyclone or equivalent fence not less than six feet in height, with opening securely locked when unattended.
Non-standard open lot: Any other type of protection or fencing or unprotected lot.
Comprehensive deductible:
$100/$500
$250/$1,000
$500/$2,500
$1,000/$5,000
$2,500/$12,500
$5,000/$25,000
Collision deductible:
$100
$250
$500
$1,000
$2,500
$5,000
Class of Employee Total Employees
Class 1A – Owners/Employees Furnished an Auto for personal use & all employees who’s principal duty it is to
operate an auto
Class 1B – Full time salespersons and managers not furnished for personal use
Class 1B – Part time salespersons and managers not furnished for personal use
Class 1C – All others full time
Class 1C – All others part time
Non-employee – under age 25
Non-employee – all other
Employee count (complete employee list required)
Page 3 of 7
Property
Location #: _______________________________ Building #: _______________
Square feet: ___________________ Year built: __________________ Number of stories: ________________
Building updates:
Plumbing:
Yes
No Year of update: __________ HVAC:
Yes
No Year of update: __________
Electrical:
Yes
No Year of update: __________ Roof:
Yes
No Year of update: __________
Is electrical panel manufactured by either Zinsco or Federal Pacic?
Yes
No
Construction:
FRAME
JM
NC
Masonry NC
Modied re resistive
Fire resistive
Is the building sprinklered?
Yes
No
Does the building have a re alarm?
Yes
No
Local alarm
Central station
Does the building have a burglar alarm?
Yes
No
Local alarm
Central station
Deductible:
$250
$500
$1,000
$2,500
$5,000
$10,000
Co-insurance:
80%
90%
100%
Property / Inland Marine / Crime Coverages Desired Limits Valuation / Deductible
Building
$ _______________________
RC
ACV
other
_____________
Deductible $ _____________
Personal property of the insured
$ _______________________
RC
ACV
other
_____________
Deductible $ _____________
Business income
$ _______________________
Monthly limit:
_____________
ALS
Employee tools
$ _______________________ Deductible $ _____________
Employee dishonesty
$ _______________________ Deductible $ _____________
Forgery
$ _______________________ Deductible $ _____________
Money / securities (inside and outside)
$ _______________________ Deductible $ _____________
Other: ___________________________________
$ _______________________ Deductible $ _____________
What is the building valuation based on?
What are desired BPP limits based on?
What are the annual sales?
False pretense:
Yes
No
Additional garage coverages:
Page 4 of 7
Garage / Auto Coverage Information
Garage / Auto Coverage Options Limits
R Non-owned
Included automatically for Auto Service Plus program
Hired
Estimated cost of hire $ ___________________
BFDOC (CA9910)
Need all individuals names
Rental reimbursement (CA9923)
$30 per day for 30 days
R Broadened garage coverages (CA2514)
Included automatically for Auto Service Plus Program
Dealers plates
Number of plates _________________________
On hook coverage
Limit $ _____________________ Deductible $ ________________
Personal injury protection (no fault states only)
Limit $ _____________________
Dealers E&O
Limit $ _____________________
Auto dealers legal defense & product related damages
Limit $ _____________________
Other: _______________________________________________
__________________________________________________________
Vehicle schedule if you have scheduled vehicles – for additional vehicles complete vehicle supplemental
Year Make Model Cost new VIN Zip Radius Use
COMP
DED
COLL
DED
Drivers list – for additional drivers complete driver list supplemental
Last name First name State
License
number
Violations & accidents
– 3 years
Date of
birth
Job title
Personal
use?
Drive other
car?
Accidents
Minor
violations
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
Have any driver been convicted of a major violation in the last 3 years?
Yes
No
If yes, list drivers: ___________________________________________________________________________________________________
Page 5 of 7
Survey of Hazards
General Underwriting Questions
1. Does applicant have an established store front?
Yes
No
2. Does applicant share a premises with any other occupants?
Yes
No
3.
Any guard dogs on premises?
Yes
No
4. Is applicant a subsidiary of another entity or have any subsidiaries?
Yes
No
If yes, explain: _______________________________________________________________________________
5. Does applicant subcontract any work?
Yes
No
If yes, explain: _______________________________________________________________________________
6.
Has coverage been declined, canceled or non-renewed in last 3 years?
Yes
No
If yes, explain: _______________________________________________________________________________
7.
Does applicant have any other business ventures not included in this submission?
Yes
No
If yes, explain: _______________________________________________________________________________
8. Has applicant had a foreclosure, repossession or bankruptcy in the last 5 years?
Yes
No
9.
Has applicant had a judgment in the last 5 years?
Yes
No
10. Are there currently serviced, charged and operable re extinguishers on premises?
Yes
No
11.
Does applicant store all ammable liquids in a UL-listed re cabinet?
Yes
No
12. Does applicant use UL-listed metal containers with self closing lids?
Yes
No
13. Does applicant have no-smoking signs posted?
Yes
No
14. General housekeeping practices
Moderate
Formal
Informal
15.
Employee safety training practices
Moderate
Formal
Informal
16. Describe type of mechanic certication (ie: ASE certied): __________________________________________
17. Describe key control procedures: _______________________________________________________________
18. Does applicant have underground gasoline storage tanks?
Yes
No
If yes, please describe: Age of tanks: _______________ Tank construction: ________________________
Describe leak monitoring method: ______________________________________________________________
Prior Carrier / Loss History (minimum 3 years)
Prior carrier Policy term
Date of
loss
Description of loss
Amount
paid
Amount
reserved
Policy
premium
Types of Vehicles:
Sales: % Repair: % Type of Vehicles
______________ % _______________ % Private passenger autos, pickups, vans, SUVs
______________ % _______________ % RVs, motorhomes, campers (incl. supplement)
______________ % _______________ % Heavy truck / semi-trailers (incl. supplement)
______________ % _______________ % Boats (describe): ________________________________________________________________
______________ % _______________ % Power sports (jet skis, ATVs, UTVs)
______________ % _______________ % Motorcycles (include supplement)
______________ % _______________ % Golf carts
______________ % _______________ % Antique or classic cars
______________ % _______________ % Bucket trucks, man lifts
______________ % _______________ % Contractors equipment (describe): _________________________________________________
______________ % _______________ %
Agricultural equipment – any farm implements?
Yes
No
Page 6 of 7
Types of Vehicles continued:
Sales: % Repair: % Type of Vehicles
______________ % _______________ % Emergency vehicles (describe): ___________________________________________________
______________ % _______________ % Buses (list all types): ____________________________________________________________
______________ % _______________ % Trailers (other than semi)
______________ % _______________ % Other (describe): ________________________________________________________________
______________ % _______________ % Total percentage all operations combined should equal 100%
Dealer operations: Percentage of new autos vs. used autos: New: ___________ Used: _____________
If non-franchise, is applicant part of the National Independent Auto Dealers Association or
a Certied Master Dealer?
Yes
No
Does applicant sell autos on consignment?
Yes
No
Does applicant operate as an auto auction?
Yes
No
Are all test drives accompanied by an employee?
Yes
No
Any overnight test drives allowed?
Yes
No
Number of vehicles sold per month: __________________
Maximum radius of pick up & delivery: __________________
Does applicant rent or lease vehicles?
Yes
No
Does applicant offer loaner vehicles?
Yes
No If yes: Is there a loaner contract in place?
Yes
No
Does applicant obtain proof of insurance?
Yes
No Does applicant verify valid driver’s license?
Yes
No
Non-dealer Operations – complete approximate percentage for all operations
Airbag installation, service or repair: ________________ % Parking lots & garages (self park) ________________ %
Alarm, stereo or navigational system: ________________ % Parts sales (uninstalled): ________________ %
Auto dismantling / salvage yard: ________________ % Gross receipts: $ ________________
Body shop: (answer questions below) ________________ % Parts Manufacturing / rebuilding: ________________ %
Brake repair: ________________ % Gross receipts: $ ________________
Car wash – full service: ________________ % Describe parts: ____________________________________________
Convenience store: ________________ % Performing enhancements: ________________ %
Gross receipts: $ ________________ Any turbo or nitrous installation?
Yes
No
Detailing: ________________ % Propane sales: ________________ %
Drive-away contractor services: ________________ % Is tank barricaded on all sides?
Yes
No
Frame straightening: ________________ % Trained technician dispensing fuel?
Yes
No
Any frame cutting or welding?
Yes
No
Tire dealer – (complete supplement) ________________ %
Fuel tank repair: ________________ % Towing – (complete supplement) ________________ %
Gasoline station – full service: ________________ % Trailer hitch installation: ________________ %
Gallons of gas sold annually: $ ________________ Transmission: ________________ %
Ignition interlock systems: ________________ % Upholstery: ________________ %
Impound yards: ________________ % Valet parking (complete supplement): ________________ %
Lift / lowering kits: ________________ % Vehicle conversions – structural: ________________ %
Machine shop – rebuilding: ________________ % Welding: ________________ %
Mobile auto repair: ________________ % Window Tinting: ________________ %
Oil / luge services: ________________ % Windshield installation / repair: ________________ %
Other (describe): _______________________________________________________________________________ ________________ %
800 Superior Avenue E., 21st Floor • Cleveland, OH 44114 • 877.528.7878 • www.amtrustnorthamerica.com
Page 7 of 7
MKT0851 10/14
Please provide the following information to complete:
Producer’s name: _________________________________________ Producer’s signature: ______________________________________
Applicant’s name: ________________________________________ Applicant’s signature: ______________________________________
Date: _______________________
Paint and body shop operations:
1.
Is spray booth NFPA compliant?
Yes
No
2. Is booth protected by an automatic sprinkler or dry chemical re suppression system?
Yes
No
3. Is paint mixing area enclosed in a non-combustible enclosure with self-closing metal door?
Yes
No
4. Is paint mixing area protected by an automatic sprinkler or dry chemical re suppression system?
Yes
No
5. Does mixing area have explosion proof electrical systems?
Yes
No
6. NFPA compliant powered ventilation in booth and mixing room?
Yes
No
7. Are all lters regularly cleaned and changed?
Yes
No
8. Maximum gallons of ammable solvent based liquid maintained at any one time: _________________________
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Completed 10 July 2021

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