Garage-Liability-Repair-Sales-Application

COMPANY INFORMATION - GARAGE DEALERS/BROKERS APPLICATION

Business Name or Insured Name *

Type of Business (Sole Proprietor, LLC, INC) *

EIN or SS *

Email *

Phone *

Date Business Started *

What does your business do? Please be detailed

Location Address *

Address Line 1

Address Line 2

City

State

Zip Code

Mailing Address if applicable

Address Line 1

Address Line 2

City

State

Zip Code

CONTACT INFORMATION

Owner Name *

First

Last

Date of Birth *

Phone *

Duties of Owner *

Driver's License Number *

Does this owner own 100% of the business? *

If not, what percentage does this owner hold in the company

Inspection Contact

Phone

Do you use a covered auto for personal use? If yes, list all persons that need this coverage.

How many vehicles are sold per year?

Upload Additional Drivers

Click or drag files to this area to upload. You can upload up to 2 files.

Name, Date of Birth, Driver's License, First CDL, and Violations

EMPLOYEE OR OTHER OWNER INFORMATION

Other Employee or Other Owner Information

Employee Name

First

Last

Date of Birth

Title

Duties

Driver's License Number

Ownership Percentage (If applicable)

Upload additional employees

Click or drag a file to this area to upload.

Include name, Date of Birth, Duties, and annual payroll

Do you have Prior Garage Insurance? *

Any claims?

Name of prior insurer if applicable

Expiration Date

Upload Loss Runs if available

Click or drag a file to this area to upload.

Upload 3 years loss runs if you have prior insurance

COVERAGES

Effective Date *

Garage Liability

$125,000
$500,000
Other/Unknown

Garage Keepers Desired? If yes, you will be contacted for more info

Dealers Physical Damage Desired? If yes, you will be contacted for more info

UNDERWRITING (EXPLAIN ALL YES RESPONSES)

IS TITLE TRANSFERED AT TIME OF SALE? *

ARE YOU EVER LISTED A LIEN HOLDER ON THE TITLE? *

DO YOU CONFIRM PURCHASER HAS INSURANCE? *

ANY INTERNET SALES OR ADVERTISING? *

DO YOUR SALESPEOPLE ACCOMPANY CUSTOMERS ON ALL DEMONSTRATION RIDES? *

DO YOU SELL SALVAGED/REBUILT/JUNK/RECONSTRUCTED TITLE AUTOS? *

DOYOU LOAN/LEASE/RENT ANY VEHICLES? *

ARE YOU OR ANY OF YOUR EMPLOYEES ENGAGED IN ANY RIDESHARE PROGRAMS I.E LYFT/UBER? *

DO YOU HAVE PROTECTED LOT? *

DO YOU PERFORM ANY SERVICE WORK, SUCH AS MECHANIC? *

DO YOU HAVE ANY DOGS ON THE PREMISES? *

DO YOU DELIVER VEHICLES TO CUSTOMERS AFTER THE SALE IS COMPLETE? *

What type of Dealer License do you have?

How Many Dealer Plates Do you Have?

Provide other helpful details below or all yes responses above.

Confirmation (Enter First and Last Name) I certify that the information provided above is accurate. I understand that wrong information may cause my quote to vary and declination. *

I certify that the information provided above is accurate. I understand that wrong information may cause my quote to vary and declination.

COMPANY INFORMATION - GARAGE DEALERS/BROKERS APPLICATION

CONTACT INFORMATION

EMPLOYEE OR OTHER OWNER INFORMATION

Other Employee or Other Owner Information

COVERAGES

UNDERWRITING (EXPLAIN ALL YES RESPONSES)

Location

Call Us

About us

Why you need an independent agent

Truckers insurance for my MC Number