GARAGE APPLICATION

Registered Business Name:
Mailing Address:
City    State        Zip
Phone:      Fax:

PROPOSED EFFECTIVE DATE:
From     To
12:01 A.M. Standard Time at the address of the Applicant
Email Address:

 Years in Business      Years Management Experience

 Business Entity: Individual    Partnership    Corporation

 Describe your Operations   

 Locations where you conduct Garage Operations
 1.    2.

 All Owners, Employees, Spouses & Children Furnished Autos
 (If more space is needed, please use the "Remarks" field at the bottom of this form)
Name
Date of Birth
Driver License Number
State of License
Furnished Auto?
Past 3 Years #
Job Description and/or Relationship
Accidents
Citations
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No

 EMPLOYEE INFORMATION
 1. Number of full-time technicians Payroll Amount
 2. Number of full-time other employees (clerical, etc.) Payroll Amount
 3. Number of part-time technicians Payroll Amount
 4. Number of part-time other employees (clerical, etc.) Payroll Amount

SALES
 1. Where do you purchase vehicles?
 2. Who drives or tows vehicles to your lot?
 3. How many times per year do you drive-away more than 300 miles from point of purchase?
 4. How many vehicles do you sell per year? How many of those are on consignment?
 5. What is your normal radius of operation?
 6. What is your sales mix?
    cars, sport utility, pickups, vans
    motorhomes
    travel trailers, mobile homes
    trucks, tractors, semi-trailers
    salvage parts
    other
 7. Describe lot security and key controls
 8. How many dealer plates do you have?
 9. Do you repossess vehicles? Yes No    If yes, explain
 10. Do you sell Salvage titled vehicles? Yes No     If yes, what percentage of vehicles require:
       cosmetic repair %   mechanical repair %   structural repair %
 11. Do you always ride along on test drives? Yes No


 SERVICE
 1. What percentage of your work is:
Body/Paint
%
 Muffler
%
 Sound System
  %
 Window Tint
  %
Tune up
%
 Radiator
%
 Tires
  %
 Other
  %
Transmission
%
 Wheel Alignment
%
 Upholstery
  %
 Describe    
Brakes
%
 Oil & Lube
%
 Wash/Detail
  %

 2. Do you sell    gasoline or     LPG    If yes, how many gallons?
 3. Do you install trailer hitches? Yes   No
 4. Do you have a spray paint booth? Yes   No    If yes, is it U/L approved? Yes   No
     Is it ventilated? Yes   No   
 5. Do you recap tires or sell recapped tires?
 6. Do you tow for hire? Yes   No      If yes, explain
 7. Describe lot security and key controls   
 PRIOR CARRIERS
Current Carrier Policy Period Policy Premium
Prior Carrier Policy Period Policy Premium
Prior Carrier Policy Preiod Policy Premium

 LOSS HISTORY FOR 3 YEARS
Date of Loss
Amount
Description of Loss

 COVERAGE REQUESTED
Garage Liability $ each accident,  $ aggregate, Deductibles
Garagekeepers $ Per location     SCL $ deductible  Collisions deductible
Dealers Physical Damage $ Per location   SCL $ deductible   Collisions deductible
Premises Medical Payments $1000
Scheduled Vehicles                SCL $ deductible   Collisions deductible

Veh.
No.

Year
Make
Body Type
V.I.N.
ACV

Veh.
No.
GVW
Radius
Use
Loss Payee

Fire Legal Liability $50,000
Uninsured Motorist $
Personal Injury Protection $ Per location
Buybacks     Transit Limit $    Driveway Radius    Value per Auto $

 Remarks:   

Application Completed By:     Date: