Fillable Garage Keepers Application (Abram Interstate Insurance)

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Garage Keepers Application (Abram Interstate Insurance)

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Garage Information Reference
Garage Information Reference
Rev. 5-2015
1
In addition to the information contained on the insurance application, the following information is required when completing the policy
screens for Garage operations in TravelersExpress
®
for Master Pac
SM
and Workers’ Compensation.
The information requested in this document is specifically designed to assist you with gathering information so that you may obtain a
Master Pac and/or Workers’ Compensation quote. The information gathered with this document is not intended to supplement or
replace the insurance application. The data captured should be entered into the TravelersExpress
®
system to start the quoting process.
While completion of this document is not required, if you elect to use it, a copy should be kept in your file for the account.
Insured Information
Federal Employers Identification Number (FEIN)
Legal Entity: Association Corporation Individual Ltd. Liability Corp. (LLC) Ltd. Liability Partnership (LLP)
Partnership Ltd. Partnership (LP) Joint Venture Trust or Estate Other:
Year business established or acquired by the current owner:
o If less than 3 years, Does the current ownership have 3 years management experience in a related field: Yes No
o Is this a franchised operation: Yes No
General Operations
Hours of Operation: No later than 10pm No later than Midnight No later than 2am Past 2am 24 Hours
o Are extended hours of operation limited to credit card only gas pumps: Yes No
Towing service: Yes No If yes: # tow trucks: 24-hour? Yes No DOT or Auto Club Towing: Yes No
Spray-painting performed in NFPA and OSHA approved booths with automatic fire suppression system: Yes No N/A
Does the applicant work on vehicles other than private passenger vehicles and light or medium trucks: Yes No
Enter the number of owned autos used in the business (not including trailers), 0 if none, or Unknown if not known
Ground transportation, including an employee van pool, regularly for 6 or more employees in a single automobile: Yes No
Are operations subcontracted or are independent contractors used for service, maintenance, or repair work: Yes No
o If yes, Subcontractors required to provide proof of General Liability limits at least equal to the applicant’s: Yes No
o Are independent contractors and subcontractors required to provide proof of WC insurance: Yes No
Applicant has no operations or subcontracted operations found on the list of ineligible operations below: Yes No
o 24-Hour operations (except credit ONLY gas pumps)
o Airbag disabling
o Armed security guards
o Auto dismantlers, rebuilders or restorers
o Auto or truck rental, leasing, loaning (ride sharing) operations
o Guard dogs on premises
o Car washes (as the predominant operation or more than one bay as an
ancillary operation)
o Custom fabrication of motor vehicles or motorcycles
o Equipment or tool rentals
o Gas stations with norepair operations
o Installation of tires not sold by insured
o Mobile “business on wheels” with no garage operation as a base
o Home- based businesses
o Ownership or sponsorship of racing vehicles
o Parking garages or operations
o Pick-up or delivery of customers’ vehicles
o Propane line installation or servicing
o Sales of auto, boat, motorcycle or recreational vehicles (used auto sales
not exceeding 15 vehicles per year is acceptable)
o Salvage or wrecking operations or yards
o Service or repair of:
– Emergency vehicles (i.e. police cars, EMT vehicles, small
ambulances, etc.)
– Motorcycles
– Off-road vehicles
– Recreational vehicles (RV’s)
– Split ring or metal-locking rim truck wheels
– Vehicles over 20,000 GVW
– Vehicles used for racing
o Rental of self-service bays
o Tire recapping or vulcanizing
o Tire sales in excess of 25% of total annual revenue
o Towing operations (as the predominant operation or more than one
tow truck as an ancillary operation)
o Transportation of freight and cargo including auto transportation
services (Drive-Away or Haul-Away contractors)
o Transportation of passengers (except courtesy transport of auto
service customers)
o Vehicle repossessions carried out by employees
Garage Information Reference
Garage Information Reference
Rev. 5-2015
2
Master Pac
Jump to Workers’ Compensation
General Operations
Gas Sales: Yes No
If yes, gallons of gasoline sold annually: #
Total annual sales from tire sales: $
Total number of used vehicles sold annually: #
Ownership or sponsorship of racing vehicles: Yes No
Disposal of hazardous materials and waste in accordance with all local, state and federal guidelines: Yes No
Total annual sales from the operation of a convenience store in conjunction with the repair garage: $
Premises Protection
Percentage of building sprinklered: 100% 80% to 99% <80% None
If percentage of building sprinklered is 80% to 99% or 100%: Life Safety only Automatic Fire Protection/Extinguishing
If the building has an automatic sprinkler system, the following confirmations are needed:
This building has a fully functioning automatic fire protection or extinguishing sprinkler system covering 80-90%, or 100% of the
building area : Yes No
I acknowledge that the Protective Safeguards Endorsement will be added to this policy and the insured's rights to payment for a fire
loss may be affected by the terms of this endorsement and I have advised / notified the insured of the potential coverage limitations:
Yes No
If a contractor is responsible for sprinkler system maintenance and inspection, indicate frequency:
Yes – Monthly Yes – Quarterly Yes – Semi-Annually Yes – Annually Not Maintained/Inspected
Sprinkler system installed for present occupancy: Yes No
Storage Practices
Bulk storage of new or used tires: Yes No
If location TIV >$1,000,000, type of flammable materials storage (check all that apply):
UL Listed Flammable Storage Cabinet Enclosed Room Outside Storage
Miscellaneous Operations
Welding: Yes No
Car wash: Yes No If yes: Total annual sales from car wash: $ : Attended Self Service
Workers’ Compensation
General Operations
Vehicle repair area is equipped with proper exhaust ventilation in accordance with OSHA ventilation standards Yes No
Employees use personal protective equipment in accordance with applicable OSHA eye and face protection standards Yes
No
Operations involve storage, treatment, or transportation of asbestos, lead, or other hazardous materials Yes No
Enter the maximum number of employees per shift at any one location
Safety program or safety training provided: Yes No
Employees routinely drive vehicles to carry out daily job responsibilities: Yes No If yes, # of drivers:
o Motor Vehicle Reports reviewed on drivers: Yes No
Any owned leased or aircraft used in business: Yes No
Coverage requested for all states (except monopolistic fund states) and locations with known business operations: Yes No
o Describe Exceptions:
o Does the applicant have coverage for states and locations not included in this request: Yes No
o Enter Carrier Name:
Garage Information Reference
Garage Information Reference
Rev. 5-2015
3
Do employees travel outside the U.S.: Yes No
o If yes, will employees travel to countries, nations or regions on the following list? Yes No
o Afghanistan
o Algeria – Kabyle region and
overland travel anywhere in
Algeria
o Angola
o Bangladesh
o Benin
o Burkina Faso
o Burundi
o Burma (Myanmar)
o Cameroon
o Cape Verde
o Central African Republic
o Chad
o Columbia – small towns &
rural areas
o Comoros
o Congo
o Congo, Democratic Republic
o Cote d’Ivoire
o Cuba
o Djibouti
o El Salvador
o Equatorial Guinea
o Eritrea
o Ethiopia
o Gabon
o Georgia
o Ghana
o Guinea
o Guinea – Bissau
o Haiti
o Honduras
o Indonesia
o Iran
o Iraq
o Israel – West Bank & Gaza
o Jamaica
o Kenya
o Kosovo
o Kyrgyzstan
o Lebanon
o Liberia
o Libya
o Madagascar
o Malawi
o Mali
o Mauritania
o Mauritius
o Mayotte
o Mexico
o Mozambique
o Niger
o Nigeria
o North Korea
o Pakistan
o Papua new Guinea
o Philippines – Island of
Mindanao & the Sulu
Archipelago
o Reunion
o Rwanda
o Saint Helena
o Sao Tome and Principe
o Saudi Araia
o Senegal
o Seychelles
o Sierra Leone
o Somalia
o Sri Lanka – Northern or
Eastern provinces
o Sudan / South Sudan
o Syria
o Tanzania
o The Gambia
o Timor
o Togo
o Tunisia
o Uzbekistan –
Surkhandarya Province
o Uganda
o Venezuela
o Yemen
o Zambia
o Zimbabwe
o Rural or
Underdeveloped areas
of Tropical
Nations/Regions not
listed above
o Will employees travel to countries, nations or regions under a U.S. State Department Travel Warning? Yes No
See U.S. Department of State Travel Warnings
o Enter the estimated number of trips during the next policy year:
o Enter the countries, nations or regions where employee(s) travel:
o Will any foreign trip be longer than 90 consecutive days (12 weeks): Yes No
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The Travelers Indemnity Company and its property casualty affiliates. One Tower Square, Hartford, CT 06183
This document does not amend, or otherwise affect, the provisions of coverage of any resulting insurance policy issued by Travelers. It is not a
representation that coverage does or does not exist for any particular claim or loss under any such policy. Coverage depends on the applicable
provisions of the actual policy issued, the facts and circumstances involved in the claim or loss and any applicable law.
© 2012 The Travelers Indemnity Company. All rights reserved. Travelers and the Travelers Umbrella logo are registered trademarks of The Travelers
Indemnity Company in the U.S. and other countries.
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Garage Keepers Application (Abram Interstate Insurance)

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Completed 10 July 2021

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