GARAGE APPLICATION – Auto Repair and Service (Non Dealer)

GENERAL INFORMATION

Policy Term: From: ______To: ______

Name: ______FEIN: ______

Entity: Individual Partnership Joint Venture Limited Liability Corp. Trust

Other Organization, including a Corporation (Please Describe) ______

Mailing Address: ______Phone #: (______) ______- ______

Location(s) / 1. ______Contact Name: ______
2. ______Website: ______

How many years in Business: ______How many years of related Experience: ______

Any work done elsewhere? (i.e. roadside, customers location, etc): ______

Describe Business operation: ______

______

______

Has similar insurance ever been cancelled, declined or refused for renewal? Yes No

If yes, explain:

PRIOR CARRIER (3 years)
Continuous Coverage / New Venture
(If above box is marked, please complete below) / Not a New Venture & without Insurance (Explain)
Not a New Venture & lapse in coverage (Explain)
Explain No insurance or Lapse: ______
Policy Year / Prior Carrier / Premiums Paid
LOSS HISTORY (3 years)

Check here if “None” See attached Loss runs

Date of Occurrence / Type / Description of Occurrence or Claim / Amount (Amt) Paid / Amt Reserved / Status
COVERAGES
Garage Liability
Symbol 29
Non-Owned “Autos Used in Your Garage Business / Each “Accident” Auto Only / Other than Auto / Aggregate other than Auto Only
$100,000 / $100,000 / $100,000 Aggregate x2 Aggregate x3
$300,000 / $300,000 / $300,000 Aggregate x2 Aggregate x3
$500,000 / $500,000 / $500,000 Aggregate x2 Aggregate x3
$1,000,000 / $1,000,000 / $1,000,000 Aggregate x2 Aggregate x3
Medical Payments
(Premises) / $500 $750 $1,000 $ 5,000
Broadened Coverages – Garage / Check here if Endorsement is desired - If selected, choose Fire legal Limit below
Includes:
Personal And Advertising Injury Coverage
Host Liquor Liability Coverage
Fire Legal Liability Coverage $50,000 $100,000
Incidental Medical Malpractice Liability Coverage
Non-Owned Watercraft Coverage
Additional Persons Insured
Limited Worldwide Liability Coverage
Described Operations / Class Description / Exposure / Location 1 / Location 2
Accessories, Alarm / Stereo, Parts, Truck Shell or Tire Sales / Gross Sales
Self Serve Car Wash / Gross Sales
Gasoline Sales / Gallons
Convenience Store Sales / Gross Sales
GarageKeepers
Symbol 30
“Autos” Left with you for Service, Repair, Storage or Safekeeping
(*ccc = Care Custody & Control) / Legal Liability / Direct Primary
Specified Causes of Loss with Collision / Specified Causes of Loss with Collision
Comprehensive with Collision
# of Autos in your c.c.c* / Limit for Each Location / Deductible Options
Loc. / Maximum / Average / Max Value
Per Auto / Max Value
for All Autos / Per Auto / Max Any one Loss
1 / $ / $ / $500 / $2,500
$1,000 / $5,000
2 / $ / $ / $500 / $2,500
$1,000 / $5,000
On Hook
(Garage Keepers)
Coverage for vehicle in tow / Legal Liability Only
Specified Causes of Loss/w Collision OR Comprehensive/w Collision
Unit Description / Limit “On Hook” / Deductible
(UM / UIM)
Uninsured / Underinsured Motorist Coverage / Not available on Service only risks
(no owned autos) / Important Notice: Signed rejection form required
(PIP)
Personal Injury Protection Coverage / Not available on Service only risks
(no owned autos) / Important Notice: Signed rejection form required
UNDERWRITING QUESTIONS
1. / Do you loan any vehicles? / 1. / Yes No
If Yes, Explain ______
2. / Do you pick up and deliver customers vehicles? / 2. / Yes No
If Yes, how far and how often______
3. / Do you perform any machining, re-machining, re-boring operations? / 3. / Yes No
If Yes, Explain ______
4. / Do you rebuild any of the following: brakes, steering systems, or restraint systems? / 4. / Yes No
5. / Do you perform any frame straightening? If yes, which type, see below / 5. / Yes No
Laser Measuring device / Mechanical Gauge (complete Supplemental)
Optical Measuring device / Make & Model ______
6. / Do you buy salvage for reconstruction? / 6. / Yes No
7. / Do you repair vehicles with damage totaling more than 75% of the ACV of the vehicle? / 7. / Yes No
8. / Do you modify, rebuild or perform conversions on vehicles? / 8. / Yes No
If yes, Explain ______
9. / If you perform hydraulic repairs, do you repair any of the components that operate the lifting apparatus? (i.e.: Components that lift persons and/or property) / 9. / Yes No
If yes, Explain ______
10. / Do you own, repair, service, or sponsor a race car? / 10. / Yes No
11. / Do you repossess autos? / 11. / Yes No
12. / Do you tow? / 12. / Yes No
If yes, For Hire ______% Rotation ______% Repo _____%
13. / Do you have a storage lot on premises? / 13. / Yes No
14. / Do you dismantle autos or have salvage operations? / 14. / Yes No
15. / Do you store vehicles overnight? If yes, what are the protections? / 15. / Yes No
Inside Storage (All Vehicles) Fully Enclosed, roofed and locked building
Outside Storage (all Vehicles) Lots have adequate lighting, and when described premises are closed for business, all entrances,
exits, openings and the entire perimeter must be protected by fences, gates, or heavy chains and locks.
Other, explain: ______
______
16. / Do you park customer’s vehicles on the street? / 16. / Yes No
17. / If you perform spray painting, do you have a spray booth? / 17. / Yes No
If yes, is it equipped with explosion proof lights, outside ventilation & bay separation? / Yes No
18. / Is your lot well lit at night? / 18. / Yes No
19. / Are signs posted to keep customers from the work area? / 19. / Yes No
20. / Are Firearms kept on the premises? / 20. / Yes No
21 / Is your lot patrolled by a security guard? / 21. / Yes No
If yes, Is the guard armed? / Yes No
22. / Do you have any other security devices? (i.e. Cameras, Alarm, etc) / 22. / Yes No
If yes, describe: ______
23. / Do you have any animals on premises? / 23. / Yes No
24. / Do you leave keys in vehicles? / 24. / Yes No
Describe how keys are controlled: ______
______
VEHICLES REPAIRED
Repair / Repair
Private passenger cars, pick-up trucks, vans, Sport Utilities / % / Motor homes, Recreational vehicles **complete (complete Motor Home & RV Repair Supp) / %
Salvage Title Autos / % / Trucks 20,000 # GVW / %
Sports Cars or high performance cars (Porsche, Corvette etc) / % / Trucks > 20,000 # GVW
(complete Heavy Truck, Bus & Equip Supp) / %
Motorcycles, Motorbikes
(complete motorcycle Repair Supp) / % / Truck tractors, 5th Wheels & Semi Trailers (complete Heavy Truck, Bus & Equip Supp) / %
Antique or Classic Vehicles / % / Farm Equipment
(complete Heavy Truck, Bus & Equip Supp) / %
Boats-Hull / % / Construction Equipment
(complete Heavy Truck, Bus & Equip Supp) / %
Boats-Motors / % / Utility trailers / %
Golf Carts / % / Other: / %
ATV’s, Jet Skis / % / Other / %
Total / 100%
SERVICE WORK. Identify by percentage the amount of each type of service work from the list below
Brakes / % / Airbags (Including Deactivating) / %
Car Wash Attended Self serve / % / Body Work / %
Custom Wheel / Rim Manufacturing / % / Detail / %
Custom Wheel / Rim Installation / % / Painting / %
Electrical / % / Gasoline/LPG Sales / %
Muffler / % / Lift Kit Installation / %
Oil & Lube / % / Hitches / %
Radiator / % / Hydraulics / %
Sound System/Alarms / % / Interlock Devices (aka Breathalyzers) / %
Tires (complete Tire Dealer Supp) / % / Performance Upgrades-Please detail: / %
Transmission / % / Suspension (not lift kits) / %
Tune-up / % / Valet Parking / %
Window Tinting / % / Welding (Complete Welder Supp) / %
Windshield Repair / % / Other: Description: / %
Windshield Replacement / % / Total / 100%

List any Additional Insured’s to be named and advise what their interest is in this operation.

Additional Insured: ______

Landlord Lessor or Leased Equipment Franchisee **Customer (**attach a copy of the contract)

Additional Insured: ______

Landlord Lessor or Leased Equipment Franchisee **Customer (**attach a copy of the contract)

Additional Insured: ______

Landlord Lessor or Leased Equipment Franchisee **Customer (**attach a copy of the contract)

Garage Application - Service Only (10-10) www.vintageunderwriters.com Page 2 of 5

LIST ALL OWNERS, PARTNERS, OFFICERS, & EMPLOYEES (active or inactive)
Name (As shown on license) / License No. / State / DOB / Violations / Accidents
Prior three years / Status / Hours
Status: Hours:
1 = Active Owner, Partner or Officer / F = Full Time (Over 20 Hours a week)
2 = Inactive owner, Partner or Officer / P = Part Time (20 or less hours per week)
3 = Mechanic / Helper
4 = Clerical
5 = Other (Explain)
SIGNATURES

I declare to the best of my knowledge that all statements herein are true and no material facts have been suppressed or misstated. I am also aware that my operation may be inspected by the insurance company.

Applicant’s Signature/Title Agent’s Signature

Applicant’s Name (Print) Agent’s Name (Print)

Date Date

Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

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