Contact Person
Cell Phone
Email
Home Address
City
State
ZIP Code
Business Name
Business Location #1
Business Location #2
Description of Operations (ex. Dealer Broker / Used Car Lot)
Years in Business (If new venture, advise years in industry/experience)
Cancelled or non-renewed in past 3 years?*
If yes, why?
Any losses in past 3 years?*
If yes, date of loss, details, amounts paid
Types of vehicles sold and percentage
Average number of autos held for sale
Average Value
Schedule Autos Requested?
If yes, provide year, make, model, and coverages desired
Coverages
Garage Liability
Each Accident*
Aggregate*
Garage keepers
Causes of Loss
Total Limits: Location #1
Location #2
Deductibles: Specified COL or Comprehensive
Collision
Drive away miles:
Premises medical payments
Uninsured motorists
Auto medical payments
Number of dealer plates
Broadened endorsement
Fire Legal: $50,000
Employee Information
Owner's Name
Drivers License #
Date of Birth
Social Security Number (You can always call us regarding your SSN if you have any concerns with entering it digitally)
Job Duties
Hours Worked
Furnished Auto?*
Employee's Name
Drivers License #
Date of Birth
Social Security Number (You can always call us regarding your SSN if you have any concerns with entering it digitally)
Hours worked
Furnished Auto?
Employee's Name
Drivers License #
Date of Birth
Social Security Number (You can always call us regarding your SSN if you have any concerns with entering it digitally)
Hours worked
Furnished Auto?
Employee's Name
Drivers License #
Date of Birth
Social Security Number (You can always call us regarding your SSN if you have any concerns with entering it digitally)
Hours worked
Furnished Auto?
Please Note: This is not an application and the figures we are quoting are an indication only, subject to a properly completed application. You do not have binding authority until we authorize you that is acceptable.
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