Travelers



GARAGE INSURANCE APPLICATION SUPPLEMENTSECTION I – GENERAL INFORMATIONGeneral Agency: FORMTEXT ?????Retail Agency: FORMTEXT ?????Underwriter: FORMTEXT ?????Producer/CSR: FORMTEXT ?????Phone: FORMTEXT ?????Phone: FORMTEXT ?????E-Mail: FORMTEXT ?????E-Mail: FORMTEXT ?????Proposed Policy Term:From: FORMTEXT ?????To: FORMTEXT ?????SECTION II – APPLICANT INFORMATIONApplicant Name FORMTEXT ?????Phone Number FORMTEXT ?????Mailing Address (incl. City, State and ZIP) FORMTEXT ?????Principal/Contact FORMTEXT ?????Years in Business FORMTEXT ?????Website: FORMTEXT ?????E-Mail: FORMTEXT ?????Business Entity: FORMCHECKBOX Individual FORMCHECKBOX Corporation FORMCHECKBOX Partnership FORMCHECKBOX LLC?? FORMCHECKBOX Other: FORMTEXT ?????Vehicle Sales: $ FORMTEXT ?????Vehicle Service: $ FORMTEXT ?????% Retail: FORMTEXT ?????% Wholesale: FORMTEXT ?????Vehicle Sales & Service: $ FORMTEXT ?????Types of Vehicles Sold/Serviced:SalesServiceSalesServiceAuto – Private Passenger New FORMTEXT ?????% FORMTEXT ?????%Truck Sales (16,001 + GVW) FORMTEXT ?????% FORMTEXT ?????%Auto – Private Passenger Used FORMTEXT ?????% FORMTEXT ?????%Buses or Motor Coaches FORMTEXT ?????% FORMTEXT ?????%Antique or Classic Cars FORMTEXT ?????% FORMTEXT ?????%Motor Home or Campers FORMTEXT ?????% FORMTEXT ?????%Motorcycle or Scooter FORMTEXT ?????% FORMTEXT ?????%Farm Equipment or Tractors FORMTEXT ?????% FORMTEXT ?????%ATV, Snowmobile, Dirt Bikes FORMTEXT ?????% FORMTEXT ?????%Boat or Watercraft FORMTEXT ?????% FORMTEXT ?????%High Performance Vehicles FORMTEXT ?????% FORMTEXT ?????%Other: FORMTEXT ????? FORMTEXT ?????% FORMTEXT ?????%SECTION III – PREMISES INFORMATIONLocation #1: Address (incl. City, State and ZIP) FORMTEXT ?????How are owned vehicles stored? FORMCHECKBOX Building FORMCHECKBOX Standard Open Lot/Protected FORMCHECKBOX Non-Standard Open Lot/UnprotectedNumber of owned vehicles stored:Average: FORMTEXT ?????Max: FORMTEXT ?????Value per vehicle:Average: $ FORMTEXT ?????Max: $ FORMTEXT ?????How are non-owned vehicles stored? FORMCHECKBOX Building FORMCHECKBOX Standard Open Lot/Protected FORMCHECKBOX Non-Standard Open Lot/UnprotectedNumber of non-owned vehicles stored:Average: FORMTEXT ?????Max: FORMTEXT ?????Value per vehicle:Average: $ FORMTEXT ?????Max: $ FORMTEXT ?????Location #2: Address (incl. City, State and ZIP) FORMTEXT ?????How are owned vehicles stored? FORMCHECKBOX Building FORMCHECKBOX Standard Open Lot/Protected FORMCHECKBOX Non-Standard Open Lot/UnprotectedNumber of owned vehicles stored:Average: FORMTEXT ?????Max: FORMTEXT ?????Value per vehicle:Average: $ FORMTEXT ?????Max: $ FORMTEXT ?????How are non-owned vehicles stored? FORMCHECKBOX Building FORMCHECKBOX Standard Open Lot/Protected FORMCHECKBOX Non-Standard Open Lot/UnprotectedNumber of non-owned vehicles stored:Average: FORMTEXT ?????Max: FORMTEXT ?????Value per vehicle:Average: $ FORMTEXT ?????Max: $ FORMTEXT ?????Standard Open Lot/Protected: Enclosed on all sides by a fence, wall or building and all openings are securely locked when unattended.Non-Standard Open Lot/Unprotected: All other open lot locations not securely enclosed and locked when unattended.SECTION IV – INSURANCE HISTORYCarrier Information: FORMCHECKBOX New Venture FORMCHECKBOX Prior Carrier Information listed belowCompanyPremiumPolicy Term (From/To)Current: FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ?????Prior Carrier: FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ?????Prior Carrier: FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ?????Loss Information: FORMCHECKBOX No Prior Losses FORMCHECKBOX Loss Runs AttachedSECTION V – BUSINESS OPERATIONSSales InformationCurrent YearPrior YearNumber of Vehicles FORMTEXT ????? FORMTEXT ?????Gross Sales$ FORMTEXT ?????$ FORMTEXT ?????Dealer Tags FORMTEXT ????? FORMTEXT ?????Vehicle Pick-up or Delivery: FORMCHECKBOX Driven by Employees Only FORMCHECKBOX Contracted Car Hauler FORMCHECKBOX Contracted Driver FORMCHECKBOX Owned Tow Truck FORMCHECKBOX Owned Tow Bar/DollyAnnual trips using employees: FORMTEXT ?????Annual trips using hired labor: FORMTEXT ?????Radius of pick-up or delivery: FORMCHECKBOX 0 – 50 miles FORMTEXT ?????% FORMCHECKBOX 51 – 300 miles FORMTEXT ?????% FORMCHECKBOX 300+ miles FORMTEXT ?????%YesNoYesNoAuctioneer FORMCHECKBOX FORMCHECKBOX Buyer Representative/Broker FORMCHECKBOX FORMCHECKBOX Internet Sales FORMCHECKBOX FORMCHECKBOX Consignment Sales FORMCHECKBOX FORMCHECKBOX Loan or Lease Vehicles FORMCHECKBOX FORMCHECKBOX Provide Rental or Courtesy Cars FORMCHECKBOX FORMCHECKBOX Finance Vehicles FORMCHECKBOX FORMCHECKBOX Repossess Vehicles FORMCHECKBOX FORMCHECKBOX Title Change Procedure FORMCHECKBOX FORMCHECKBOX Keys, Plates and Tags Secured in Lock Box FORMCHECKBOX FORMCHECKBOX Do you require proof of insurance and obtain a copy of driver’s license before test drives? FORMCHECKBOX FORMCHECKBOX Do you sell vehicles you have altered or converted from the original factory design? FORMCHECKBOX FORMCHECKBOX Are employees allowed to use vehicles held for sale for personal use? FORMCHECKBOX FORMCHECKBOX Do you immediately report all drivers hired during the policy period to your agent? FORMCHECKBOX FORMCHECKBOX Explain all Yes responses: FORMTEXT ?????Service InformationCurrent YearPrior YearService Bays FORMTEXT ????? FORMTEXT ?????Gross Sales$ FORMTEXT ?????$ FORMTEXT ?????Repair Tags FORMTEXT ????? FORMTEXT ?????Scope of OperationsAlarm, Stereo or Navigational Systems FORMTEXT ?????%Roadside/Assistance/Mobile Repair FORMTEXT ?????%Alignment FORMTEXT ?????%Salvage Yards FORMTEXT ?????%Auto Dismantling FORMTEXT ?????%Tire Sales – New FORMTEXT ?????%Body Shop/Frame Work FORMTEXT ?????%Tire Sales – Used FORMTEXT ?????%Brake Services FORMTEXT ?????%Towing Services FORMTEXT ?????%Car Wash FORMTEXT ?????%Trailer Hitch FORMTEXT ?????%Convenience Store FORMTEXT ?????%Upholstery FORMTEXT ?????%Gasoline Station – Full Service FORMTEXT ?????%Used Part Sales FORMTEXT ?????%Gasoline Station – Self Service FORMTEXT ?????%Vehicle Maintenance or Repair FORMTEXT ?????%Oil/Lube Services FORMTEXT ?????%Vehicle Painting FORMTEXT ?????%Performance Enhancement FORMTEXT ?????%Window Tinting FORMTEXT ?????%YesNoN/AAre customers allowed in service area? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Is smoking prohibited in all service areas and signs are posted? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Fire extinguishers are serviced annually and currently tagged? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Solvents and flammables stored in approved receptacle? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Painting is done in a UL approved spray painting booth? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Welding operations are separated from areas designated for painting operations? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Are oil rags and waste products disposed of properly? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Other ServicesDescribe any other services performed by the insured or on the insured premises: FORMTEXT ?????SECTION VI – EMPLOYEE & NON-EMPLOYEE INFORMATIONList all Owners, Employees, Drivers and Household Members:Loc #NameStateLicense No.MVR (Y or N)Status(A, B, C or D)Hours (FT/PT) Auto Usage(F, B, N) 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 ?????Have all owners, employees, and drivers been disclosed above? FORMCHECKBOX Yes FORMCHECKBOX NoFailure to report all drivers may result in termination or non-renewal of your policy.STATUS:ARegular Operator: Owner, Partner, Salesperson, ManagerBOther Employee: Clerical Staff, Lot StaffCNon-Employee: In-active Owners, Spouses, ChildrenDContract DriverAUTO USAGE:FFurnished a vehicleBBusiness UseNNoneSECTION VII – OWNED AUTOS / VEHICLES NOT HELD FOR SALEList all vehicles owned by the Applicant used for business or personal purposes not for sale to the public:YearMakeModelVINCost NewLoss Payee FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????SECTION VIII – REQUESTED COVERAGE AND LIMITS OF INSURANCEGarage LiabilityEach Accident$ FORMTEXT ?????Aggregate$ FORMTEXT ?????Deductible$ FORMTEXT ?????Garagekeepers Legal LiabilityEach Auto$ FORMTEXT ?????Each Location$ FORMTEXT ?????Deductible$ FORMTEXT ????? FORMCHECKBOX Comprehensive FORMCHECKBOX Collision FORMCHECKBOX Specified Causes of LossDealers Open LotEach Auto$ FORMTEXT ?????Each Location$ FORMTEXT ?????Deductible$ FORMTEXT ????? FORMCHECKBOX Comprehensive FORMCHECKBOX Collision FORMCHECKBOX Specified Causes of LossMedical PaymentsAuto$ FORMTEXT ?????Garage Operations$ FORMTEXT ?????Uninsured /UnderinsuredMotorist/PIPPer Accident/Statute$ FORMTEXT ?????Dealer Tags# FORMTEXT ?????Additional Coverages FORMCHECKBOX Broad Form Coverage - Garage FORMCHECKBOX Broadened Dealers Liability FORMCHECKBOX False PretenseFRAUD STATEMENTSFLORIDA: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.Refer to the Core Application for all Fraud Statements.SIGNATURESApplicant SignatureTitleDateProducer SignatureDateAgent Name and Address ................
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