Date:    Agency Name    Producer Name      

Phone # E-mail address  Fax #       

A. GENERAL INFORMATION                       

Applicant’s Legal Name

Address Apt/Suite

City

State

County

Proposed Eff Date

Legal Entity

Years in Business in Current Name

Have you owned a similar business or had any change in ownership, management, or name of your current

    business in the past five years?      yes         no

Is your business a subsidiary of another entity or does your business have any subsidiaries?   yes     no

Is the owner active in business?     yes     no

Owner's Name

B. LOSS HISTORY

Term

Carrier

Auto Liab

Phys Damage

General Liab

GKLL

On Hook

Total

Current:

1^st Prior:

2^nd Prior:

3^rd Prior:

C. OPERATIONS

1.  Describe all business operations conducted by applicant, including management experience, training, etc.

Does your business:

Y/N

%

Y/N

%

Do Auto Repair

Involuntary Repossessions

Do Auto body work

Other (explain below)

Towing

Sell used auto parts

Voluntary Repossessions

Sell used or recapped tires?

Other:

What type of repair or service work is performed?

What training have the mechanics or body shop workers received?   (Fact. Trained/ Certified)

Any cameras or alarms on storage lot?  yes   no

Are the storage lots completely fenced and lighted?        yes       no

Types of towing agreements.

Y/N

%

Y/N

%

Y/N

%

Motor Clubs

Dealerships

Police

General Public

Commercial

Other

Other:

% of trips per year between

1   →   50 miles

201 → 500 miles

51  →   200 miles

over 500 miles

D. DRIVERS

  How many drivers have been employed over 1 year?

  How many drivers were hired in the last 12 months

  List Drivers, age, and years experience:

E. EQUIPMENT

Year       Make               GVW                          Classification         Cost new

On Hook limit

H. Coverages & Limits

Commercial Auto Coverage

Liability Limits

Comprehensive Ded

Med Pay

Collision Ded

PIP

UM

Prefer split limits for UM

UIM

Prefer split limits for UIM

Hired Car

Non Owned

Garage Keepers

Loc 1 Limits

Loc 2 Limits

General Liability

Receipts for Auto Repair

Other classes

Exposure

I. Premium

Liability Premium

General Liability

On Hook

Risk is currently paying.

Are Limits same as above?

Premium you are looking for