Business Trade Name:
First Name:
Last Name:
Home Phone:
 Work Phone:
 EXT.
Cell Phone:
 E-Mail Address:
Home Address:
Locations/Premises where you conduct Business Operations:
GENERAL INFORMATION
Business Hours:
Type of Business:
 Business Entity:
Years of Experience:
 Describe Your Operations:
Employee Information
Driver License
Number
 Full or Part
Time
First Name
 Last Name
 DOB
 Job Title/Duties
Employee #1:
Employee #2:
Employee #3:
Employee #4:
Employee #5:
Employee #6:
Employee #7:
Garage Liability Only
Please skip business liability
section if you are dealing
with Auto Repair Shop and
Vehicle Sale.
Lot:
 sq/ft
 Shop Size:
 sq/ft
 Public Parking:
 # of Bays:
Vehicle Sale:
 Sale/Store Salvage Autos:
 Pick up or delivery
autos not owned:
Maximum value of autos held at location?
 $
 Alarm Type:
More than one location?
(check box)
Average value per auto?
 $
Business Liability - Liquor
Store,  Bakery, Market,
Restaurant, ETC..
 Business Liability Only
Lot Size:
 sq/ft
 Store Size:
 sq/ft
 Public Parking:
Age of Building:
 Fire Extinguisher:
 Alarm:
Equipment Used:
Business Exposure
Right of Business:
Left of Business:
Rear of Business:
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Prior Insurance:
 Carrier:
 Policy Period:
Policy #:
 Losses:
 Exp. Date:
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Coverages
Liability Limits:
 Liability Deductible:
Each Aggregate:
Premises Medical Payments:
Fire Legal Liability:
 $50,000
Garage keepers - Auto Repair Shops
Coverage for customers vehicles while in your car, custody &
control - Coverage based on Maximum value of autos held at
location and Maximum value per auto.
Dealers Physical Damage
Coverage for damage to auto's while held for sale.
-Coverage based on Maximum value autos held at location
and Maximum value per auto.
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Garage Liability