APPLICATION FOR GARAGE POLICY



P.O. Box 5100 Scottsdale, Arizona 852619200 E Pima Ctr. Pkwy., Ste. 350 Scottsdale, Arizona 852581-800-873-9442APPLICATION FOR GARAGE POLICYProposed Policy Period:From FORMTEXT ?????To FORMTEXT ?????Business Trade Name: FORMTEXT ?????Applicant: FORMTEXT ?????Mailing Address: FORMTEXT ?????City: FORMTEXT ?????County: FORMTEXT ?????State: FORMTEXT ??Zip Code: FORMTEXT ?????Phone: FORMTEXT ?????Internet Address (If any): FORMTEXT ?????FEIN: FORMTEXT ?????Years in Business: FORMTEXT ???Years Sales/Repair Experience: FORMTEXT ???Business Entity: FORMCHECKBOX Individual FORMCHECKBOX Partnership FORMCHECKBOX Corporation FORMCHECKBOX Other: FORMTEXT ?????Describe your Operations: FORMTEXT ?????Locations/Premises where you conduct Garage Operations:1. FORMTEXT ?????2. FORMTEXT ?????GENERAL INFORMATION1.What are your normal business hours? FORMTEXT ?????2.Are autos stored at your premises after normal business hours? FORMCHECKBOX Yes FORMCHECKBOX Noa.If yes, describe your theft barriers/storage at each location, for autos you OWN (building, fence & gate or post & cable):Loc. 1.: FORMTEXT ?????Loc. 2.: FORMTEXT ?????b.If yes, describe your theft barriers/storage at each location, for autos you do not OWN (building, fence & gate or post & cable):Loc. 1.: FORMTEXT ?????Loc. 2.: FORMTEXT ?????c.Do you own or lease Location 1? FORMCHECKBOX Own FORMCHECKBOX Leased.Do you own or lease Location 2? FORMCHECKBOX Own FORMCHECKBOX Lease3.Do you have or maintain animals on your premises? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, what types/breeds? FORMTEXT ?????Are these animals pets? FORMCHECKBOX Yes FORMCHECKBOX NoAre they used for security purposes? FORMCHECKBOX Yes FORMCHECKBOX NoDo you maintain any other security measures not already listed? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, explain: FORMTEXT ?????4.Please provide value and number of autos stored at each location:Maximum Value of ALL AutosAverage Value per AutoMaximum Value per AutoAverage No.of AutosMaximum No.of AutosLocationNo. 1$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????LocationNo. 2$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????5.Describe your key controls during business hours: FORMTEXT ????? After business hours: FORMTEXT ?????If a key box is used, describe location of key box (in building or attached to autos): FORMTEXT ?????6.Do you pick up or deliver autos not owned by you? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, explain: FORMTEXT ?????Do you tow for hire? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, explain: FORMTEXT ?????7.Who drives or tows vehicles to your premises? FORMTEXT ?????8.What is your normal radius of operations? FORMTEXT ?????9.Do you loan or lease autos? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, do you loan or lease autos to customers while their auto is being repaired? FORMCHECKBOX Yes FORMCHECKBOX NoDo you loan or lease autos for shorter than twelve (12) months? FORMCHECKBOX Yes FORMCHECKBOX No10.Do you sell or store salvaged autos? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, please indicate the purpose:Sale of Salvage Titled Autos FORMTEXT ???%Rebuilding/Repairing Customers Autos FORMTEXT ???%Sale of Used Parts FORMTEXT ???%Other FORMTEXT ???%Explain: FORMTEXT ?????11.List ALL Owners, Employees & Drivers:NameDOBDriver’s License No.State of DLCDL?Furnished Auto? Y/NWorksat Loc. No.Violations & Accidents Past Three Yrs.Full orPartTimeJob Title/DutiesY/NClass FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ??? FORMTEXT ????? FORMTEXT ? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ??? FORMTEXT ????? FORMTEXT ? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ??? FORMTEXT ????? FORMTEXT ? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ??? FORMTEXT ????? FORMTEXT ? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ??? FORMTEXT ????? FORMTEXT ? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ??? FORMTEXT ????? FORMTEXT ? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? FORMTEXT ? FORMTEXT ? FORMTEXT ? FORMTEXT ??? FORMTEXT ????? FORMTEXT ? FORMTEXT ?????12.List ALL Family members and non-family members (except customers):(Indicate if they are furnished an auto for personal use or if they may be provided an auto for regular use, but not regularly furnished.)NameDOBDriverLicense No.Stateof DLWill drive for or Work in business?Furnished Auto?*Violations & Accidents Past Three Yrs.Relationship FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? FORMTEXT ??? FORMTEXT ??? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? FORMTEXT ??? FORMTEXT ??? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? FORMTEXT ??? FORMTEXT ??? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? FORMTEXT ??? FORMTEXT ??? FORMTEXT ????? FORMTEXT ?????*P=Personal use; R=Regular use; NRF=Not regularly furnished.13.Will anyone listed in either Items 11. or 12. use an auto for reasons other than listed? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, please explain: FORMTEXT ?????14.Have all members of your household been disclosed on this application? FORMCHECKBOX Yes FORMCHECKBOX NoIf no, explain: FORMTEXT ?????15.Have all drivers, such as children away from home or in college, who may operate your vehicles on a regular or infrequent basis, been listed on this application? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/AINSURANCE HISTORY16.Has your insurance been cancelled or non-renewed within the last three years (Not applicable in Missouri)? FORMCHECKBOX Yes FORMCHECKBOX Noa.If yes, please explain: FORMTEXT ?????b.A minimum of three year history is required. If three year history is unavailable, please explain: FORMTEXT ?????Current Carrier: FORMTEXT ????? Eff. Date: FORMTEXT ????? Exp. Date: FORMTEXT ????? Policy Premium: $ FORMTEXT ?????Prior Carrier: FORMTEXT ????? Eff. Date: FORMTEXT ????? Exp. Date: FORMTEXT ????? Policy Premium: $ FORMTEXT ?????Prior Carrier: FORMTEXT ????? Eff. Date: FORMTEXT ????? Exp. Date: FORMTEXT ????? Policy Premium: $ FORMTEXT ?????Date of LossAmountDescription of Loss FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ?????UNDERWRITING INFORMATION17.Please provide your percentage of operations (Percentages MUST equal one hundred percent [100%]).RepairSalesPrivate passenger cars, SUVs pick-up trucks, vans FORMTEXT ???% FORMTEXT ???%Motorhomes FORMTEXT ???% FORMTEXT ???%Motorcycles FORMTEXT ???% FORMTEXT ???%Motor coaches or buses FORMTEXT ???% FORMTEXT ???%Watercraft (boats, jet skis, etc.) FORMTEXT ???% FORMTEXT ???%Dirt Bikes or ATVs FORMTEXT ???% FORMTEXT ???%All other recreational autos FORMTEXT ???% FORMTEXT ???%Farm Equipment FORMTEXT ???% FORMTEXT ???%Construction/Contractor’s Equipment FORMTEXT ???% FORMTEXT ???%Travel trailers or camper trailers FORMTEXT ???% FORMTEXT ???%Utility trailers or livestock trailers FORMTEXT ???% FORMTEXT ???%Trucks, tractors, semi-trailers FORMTEXT ???% FORMTEXT ???%Salvage titled autos FORMTEXT ???% FORMTEXT ???%Salvage parts FORMTEXT ???% FORMTEXT ???%Other: FORMTEXT ????? FORMTEXT ???% FORMTEXT ???%TOTAL100%100%18.Total Gross Receipts from:All Vehicle/Equipment Sales $ FORMTEXT ?????All Repair $ FORMTEXT ?????Other Product Sales $ FORMTEXT ?????Tow Truck Operations $ FORMTEXT ?????19.Where do you purchase vehicles? FORMTEXT ?????Do you buy or sell vehicles on the Internet? FORMCHECKBOX Yes FORMCHECKBOX NoExplain: FORMTEXT ?????20.Do you drive-away more than three hundred (300) miles from point of purchase? FORMCHECKBOX Yes FORMCHECKBOX No If yes, how often? FORMTEXT ?????21.How many vehicles do you sell per year? FORMTEXT ?????How many of those are on consignment? FORMTEXT ?????22.How many plates do you have? Dealer FORMTEXT ????? Registration/Transporter FORMTEXT ?????Transporter plate numbers: FORMTEXT ?????Describe how transporter plates are being used: FORMTEXT ?????Where are plates stored when not in use: FORMTEXT ?????23.Do you repossess vehicles? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, are these autos you have sold? FORMCHECKBOX Yes FORMCHECKBOX NoDo you repossess autos for banks or other dealers? FORMCHECKBOX Yes FORMCHECKBOX No24.Test drives: Do you always obtain a copy of the customer’s license? FORMCHECKBOX Yes FORMCHECKBOX NoDo you obtain proof of insurance when available? FORMCHECKBOX Yes FORMCHECKBOX NoDo you always ride along? FORMCHECKBOX Yes FORMCHECKBOX No25.List the percentage of your work (Percentages MUST equal one hundred percent [100%]):Type of WorkPercentType of WorkPercentOil & Lube FORMTEXT ???%Wash/Detail FORMTEXT ???%Tune-Up FORMTEXT ???%Window Tint FORMTEXT ???%Muffler FORMTEXT ???%Clear Coating FORMTEXT ???%Radiator FORMTEXT ???%Stereo System FORMTEXT ???%Electrical FORMTEXT ???%Alarm System FORMTEXT ???%Brakes FORMTEXT ???%Transmission FORMTEXT ???%Hitches FORMTEXT ???%Windshield FORMTEXT ???%Upholstery FORMTEXT ???%Lift Kit Installation FORMTEXT ???%Tires (New) FORMTEXT ???%Suspension (Not Lift Kits) FORMTEXT ???%Tires (Used) FORMTEXT ???%Wheel Alignment FORMTEXT ???%Frame Work FORMTEXT ???%Performance Adjustments FORMTEXT ???%Painting FORMTEXT ???%Other: FORMTEXT ????? FORMTEXT ???%Body Work FORMTEXT ???%Other: FORMTEXT ????? FORMTEXT ???%26.Do you do any welding? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, explain: FORMTEXT ?????27.Do you have a spray paint booth? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, is it U/L approved? FORMCHECKBOX Yes FORMCHECKBOX NoIs it ventilated? FORMCHECKBOX Yes FORMCHECKBOX NoAre fixtures covered/protected? FORMCHECKBOX Yes FORMCHECKBOX NoIs paint stored in fire-resistive cabinets outside the paint booth? FORMCHECKBOX Yes FORMCHECKBOX No28.Do you sell gasoline? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, how many gallons per year? FORMTEXT ?????Do you sell LPG? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, how many gallons per year? FORMTEXT ?????29.Do you recap tires or sell recapped tires? FORMCHECKBOX Yes FORMCHECKBOX NoCOVERAGE REQUESTED30.Check applicable box(es): FORMCHECKBOX GARAGE LIABILITYEach Accident Limit$ FORMTEXT ?????Aggregate Limit FORMCHECKBOX 1 x FORMCHECKBOX 2 x FORMCHECKBOX 3 x$ FORMTEXT ?????Deductible Liability$ FORMTEXT ????? FORMCHECKBOX GARAGEKEEPERS (Coverage for customers’ vehicles while in your care, custody and control) FORMCHECKBOX Legal Liability FORMCHECKBOX Direct PrimaryMaximum Limit Per Vehicle:$ FORMTEXT ?????Causes of Loss: FORMCHECKBOX Specified Causes w/Collision FORMCHECKBOX Comprehensive w/CollisionTotal Limits:Location No. 1:$ FORMTEXT ?????Location No. 2:$ FORMTEXT ?????Deductibles:Specified Causes or Comprehensive Deductible$ FORMTEXT ?????Collision Deductible$ FORMTEXT ?????Maximum Deductible Per Loss$ FORMTEXT ?????In-Transit Limits (On-Hook): $ FORMTEXT ????? per auto (Garagekeepers coverage required to qualify for In-Transit Coverage)Number of autos being towed or carried per each transporter: FORMTEXT ????? FORMCHECKBOX DEALERS PHYSICAL DAMAGE (Coverage for damage to autos while held for sale)Causes of Loss: FORMCHECKBOX Specified Causes w/ Collision FORMCHECKBOX Comprehensive w/ CollisionTotal Limits:Location No. 1:$ FORMTEXT ?????Location No. 2:$ FORMTEXT ?????Deductibles:Specified Causes or Comprehensive Deductible$ FORMTEXT ?????Collision Deductible$ FORMTEXT ?????Maximum Deductible Per Loss$ FORMTEXT ?????Type: FORMCHECKBOX New FORMCHECKBOX UsedMaximum Limit Per Vehicle:$ FORMTEXT ?????Interests Covered: FORMCHECKBOX Owner FORMCHECKBOX Owner and Creditor (Bank) FORMCHECKBOX ConsignmentDrive-away Miles (if over three hundred [300] miles): FORMTEXT ?????Other Limits: At Temporary Locations: $ FORMTEXT ?????While in Transit: $ FORMTEXT ?????Loss Payee: FORMTEXT ?????Loss Payee Address: FORMTEXT ????? FORMCHECKBOX MEDICAL PAYMENTS:Applicable to: FORMCHECKBOX Garage Operations FORMCHECKBOX Autos FORMCHECKBOX BothLimits: FORMCHECKBOX $500 FORMCHECKBOX $1,000 FORMCHECKBOX $2,500 FORMCHECKBOX $5,000 FORMCHECKBOX UNINSURED MOTORIST: $ FORMTEXT ?????PERSONAL INJURY PROTECTION: $ FORMTEXT ????? FORMCHECKBOX ADDITIONAL INSURED: FORMTEXT ?????Address: FORMTEXT ?????Explain the relationship there will be between the named insured and the additional insured: FORMTEXT ????? FORMCHECKBOX SPECIFICALLY DESCRIBED AUTOSVehicle No.YearMakeBody TypeVINACVGVW1 FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????2 FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????3 FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Vehicle No.RadiusPersonal Service or Commercial Use?Filings RequiredCoverages Desired? Y/NLoss PayeeYes/NoState/FederalLiabilityPhysical DamagesOther1 FORMTEXT ????? FORMTEXT ????? FORMTEXT ??? FORMTEXT ????? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ?????2 FORMTEXT ????? FORMTEXT ????? FORMTEXT ??? FORMTEXT ????? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ?????3 FORMTEXT ????? FORMTEXT ????? FORMTEXT ??? FORMTEXT ????? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ?????ADDITIONAL COVERAGES REQUESTED31.Check applicable box(es): FORMCHECKBOX CA 20 01 Lessor-Additional Insured & Loss Payee FORMCHECKBOX CA 20 27 Registration Plates Not Issued For A Specific Auto FORMCHECKBOX CA 25 03 False Pretense FORMCHECKBOX CA 25 08 Personal Injury Liability FORMCHECKBOX CA 25 10 Damage To Rented Premises Liability FORMCHECKBOX $50,000 FORMCHECKBOX $100,000Other FORMTEXT ????? FORMCHECKBOX CA 25 14 Broadened Coverage (Includes Personal Injury Liability and Damage To Rented Premises) FORMCHECKBOX CA 99 10 or CA 99 18 Drive Other Car (Dealers only) FORMCHECKBOX WHI 26-0401 Federal Odometer Errors and OmissionsFILING INFORMATION32.Do you hold an FMCSA permit or DOT registration? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, provide: US DOT No. FORMTEXT ????? MC No. FORMTEXT ????? Base State FORMTEXT ??State filings required? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, list states and provide necessary state motor carrier number, if applicable: FORMTEXT ?????Provide exact name and address as shown on application for filings, permits, certificates, etc.: FORMTEXT ?????Are there any special requirements needed for city permits, Certificates of Insurance, oversize and/or overweight permits? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, provide details: FORMTEXT ?????Remarks: FORMTEXT ?????PROPERTY INFORMATION33.Location where you conduct garage operations: FORMTEXT ?????34.Coverage/Valuation Requested:Subject ofInsuranceAmountCo-Insurance PercentProtectionClassValuation: ACV or RCCoverage Form: Basic, Broad or SpecialDeductibleBuilding CoverageBldg. 1$ FORMTEXT ????? FORMTEXT ??? FORMTEXT ????? FORMTEXT ??? FORMTEXT ?????$ FORMTEXT ?????Bldg. 2$ FORMTEXT ????? FORMTEXT ??? FORMTEXT ????? FORMTEXT ??? FORMTEXT ?????$ FORMTEXT ?????Business PersonalPropertyBldg. 1$ FORMTEXT ????? FORMTEXT ??? FORMTEXT ????? FORMTEXT ??? FORMTEXT ?????$ FORMTEXT ?????Bldg. 2$ FORMTEXT ????? FORMTEXT ??? FORMTEXT ????? FORMTEXT ??? FORMTEXT ?????$ FORMTEXT ?????Business Income:Bldg. 1With ExtraExpense$ FORMTEXT ????? FORMTEXT ??? FORMTEXT ????? FORMTEXT ??? FORMTEXT ?????$ FORMTEXT ?????Without Extra Expense$ FORMTEXT ????? FORMTEXT ??? FORMTEXT ????? FORMTEXT ??? FORMTEXT ?????$ FORMTEXT ?????Bldg. 2With Extra Expense$ FORMTEXT ????? FORMTEXT ??? FORMTEXT ????? FORMTEXT ??? FORMTEXT ?????$ FORMTEXT ?????Without Extra Expense$ FORMTEXT ????? FORMTEXT ??? FORMTEXT ????? FORMTEXT ??? FORMTEXT ?????$ FORMTEXT ?????35.Building InformationBuildingNo.BuildingAgeBuildingConstr.TotalSq. Ft.BuildingTotalSq. Ft.OccupiedNo. ofStoriesSprinklerSystemFireProtectionSystemBurglar Alarm—Type FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Central Station FORMCHECKBOX Local FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Central Station FORMCHECKBOX Local FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Central Station FORMCHECKBOX Local36.Building Improvements: Provide year updatedWiringRoofPlumbingHVACOtherBldg. 1 FORMTEXT ???? FORMTEXT ???? FORMTEXT ???? FORMTEXT ???? FORMTEXT ????Bldg. 2 FORMTEXT ???? FORMTEXT ???? FORMTEXT ???? FORMTEXT ???? FORMTEXT ????37.Operation Safeguards:Welding: FORMCHECKBOX Inside FORMCHECKBOX Outside FORMCHECKBOX Safeguards: FORMTEXT ?????This application does not bind the applicant or the Company to an agreement. However, the information stated on the application shall be the basis of the contract should a policy be issued. The application does not provide coverage orlimits and may reflect different coverages or limits than offered by the Company.FRAUD WARNINGS: Attach completed WHI APP-152, State Fraud Notification Compliance form.APPLICANT’S NAME: FORMTEXT ?????APPLICANT’S SIGNATURE: DATE: FORMTEXT ?????(Authorized owner, partner or executive officer)PRODUCER’S NAME: FORMTEXT ?????DATE: FORMTEXT ?????INDIVIDUAL TO CONTACT FOR INSPECTION/AUDIT:NAME: FORMTEXT ?????PHONE NUMBER: FORMTEXT ????? ................
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