Garage Keeper Insurance Form

Applicant Name:

Mailing Address:

Proposed Policy Period: To:

Location #1:

Location #2:

Other:

Insured's Website Address:

Inspection and Audit Contact / Phone Number:

Years in business: Years of experience in this field:

NATURE OF BUSINESS
DEALER:
NON-DEALER:
Other:
UNDERWRITING INFORMATION
1. Engage in any other operations? 5. Structurally alter or convert vehicles from their original design?
2. Sponsor sporting or social events? 6. Engage in auto pawning?
3. Repossess vehicles for others? 7. Allow customers in the work area?
4. Work on aircraft, or at airport, seaport or railroad premises? 8. Own or operate a car crusher or stack salvaged autos more than two high?
EXPLAIN ALL YES REPONSES:
PLEASE INDICATE PERCENTAGE OF THE FOLLOWING TYPE OF AUTOS YOU ARE INVOLVED IN
Sales Repair
Boats - Other Than Jet Skis % %
Buses **include complete list of bus types and passenger capacity** % %
Contractors Equipment **include complete list of equipment** % %
Emergency or Public Livery **include complete list of vehicle types** % %
Farm Equipment **include complete list of equipment** % %
Golf Carts % %
Heavy Truck (over 26,000 GVW) **supplement required** % %
Jet Skis % %
Kit Cars or Other Auto Manufacturing % %
Mobile Homes (non-motorized) % %
Motorcycles, ATVs, Scooters, Snowmobiles **supplement required** % %
Private Passenger Type Including Light & Medium Trucks - New % %
Private Passenger Type Including Light & Medium Trucks - Used % %
Recreational Vehicles, Motorhomes and Campers % %
Semi Trailers % %
Trailers - Other than Semi Trailers % %
NON-DEALERS OPERATIONS
Alarm, Stereo or Navigational System % Handicap Vehicle Modification %
Auto Dismantling / Salvage % Gasoline Station - Self Service %
Auto Maintenance or Repair Incl Bedliner % Impound Yards %
Auto Painting with UL approved spray booth % Mobile Auto Repair / Roadside Assistance %
Auto Painting without UL approved spray booth % Oil/Lube Service %
Auto Parts (uninstalled) Receipts: % Parking Lots & Garages (self park) %
Body Shop % Tire Dealers - New %
Butane, Propane or other Liquefied Gas Sales % Tire Dealers - Used, Retreads or Split Rims %
Car Wash - Full Service % Trailer Hitch Installation or Repair %
Convenience Store Receipts: % Upholstery %
Detailing % Valet Parking **supplement required** %
Driveaway Contractor or Wrecker Service % Van Conversion %
Frame or Unibody Straightening % Welding %
Fuel Conversion % Window Tinting %
Gasoline Station - Full Service % Windshield Installation/Repair %
Other: %
VEHICLE STORAGE & VALUES
Owned Autos Non-Owned Autos
How are vehicles stored?



How are vehicles stored?



Maximum value any one Auto? Maximum number of Autos? Maximum value any one Auto? Maximum number of Autos?
*Standard Lot: Standard open lots are open parking storage lots enclosed on all sides by a metal cyclone or equivalent fence not less than six feet in height; or bounded on one or more sides by the wall or walls of a building, with no unprotected openings, and with the exposed sides of the lot enclosed by a metal cyclone or equivalent fence not less than six feet in height, with openings securely locked when unattended. Non-Standard Lot: Any other type of protection or fencing. Unprotected Lots: All Other
EMPLOYEE AND NON-EMPLOYEE INFORMATION
YOU MUST COMPLETE THE FOLLOWING INFORMATION FOR ALL EMPLOYEES, DRIVERS AND HOUSEHOLD MEMBERS
Loc # Name and Driver's License # & State Date of Birth Violations & Accidents Prior Three Years Status Hours Worked Auto Use
STATUS:
1. Active Owner, Partner or Officer 7. Spouse of Owner, Partner or Officer
2. Inactive Owner, Partner or Officer 8. Children of Owner, Partner or Officer
3. Salesperson 9. Spouse of any other person furnished an auto
4. Lot Person 10. Children of any other person furnished an auto
5. Mechanic 11. Occasional or Contract Driver
6. Clerical 12. Other:
HOURS WORKED: AUTO USE:
F = Full Time (Over 20 hours per week) A = Furnished a covered auto for personal use
P = Part Time (20 or less hours per week) B = Uses a covered auto strictly for business use
N = Non-Employee C = Does not drive a covered auto
THREE-YEAR PRIOR CARRIER AND LOSS HISTORY
Current Carrier Policy Period Policy Premium
Prior Carrier Policy Period Policy Premium
Prior Carrier Policy Period Policy Premium
Date of loss Amount paid/reserve Description of loss including driver
COVERAGES & LIMITS
Garage Liability Limit of Liability Deductible
Auto Each Accident
Other Than Auto Each Accident
Other Than Auto Aggregate Limit
Dealers Open Lot Limit of Coverage Deductible



Limit Per Location Other Than Collision
Limit Per Auto Collision
Garagekeepers Limit of Coverage Deductible





Limit Per Location Other Than Collision
Limit Per Auto Collision
In-Tow Coverage
Limit Per Tow Truck # of Tow Trucks
Medical Payments Auto Garage Operations


(includes Personal Injury & $50,000 Fire Legal)
Limit

Name
Address
Insurable Interest
Uninsured Motorists Coverage Each Accident Number of Dealer Tags:
Underinsured Motorists Coverage Each Accident
Personal Injury Protection Per Statute
Radius of Pickup & Delivery:
Dealer's Errors & Omissions:

(optional)