Automotive Specialty Insurance
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Program Application

Main Content of the Garage Form and Link to the PDF Application.

GENERAL INFORMATION
d.b.a. Name:
Contact Name/Title:
Mailing Address Information
Mailing Address: City:
State: Zip:
Premise Address Information
Premise Address: City:
State: Zip:
Phone #: Fax #: Cell #:
Web Address:
Email Address:
Year Established:
Are you a New Venture?
Applicant operates as:
Coverage Currently In Force?
Coverage Term From: to
If coverage is in force, please attach 5 years of currently valued loss reports
List Major Owners/Shareholders
Name Title % Ownership
Prior Coverage Information
Coverage Carrier Expiration Date Expiring Premium
Liability
Property
Auto
Workers Comp
Umbrella
Description of Business Operations
Property Section - Required information for each location to be insured
Coverage Limit * Valuation Type Deductible
Building $ $
Leashold Improvements $ $
Business Personal Property $ $
Raw Materials $ $
Work in Progress (WIP) $ $
Stock & Inventory $ $
Computer Hardware $ $
Computer Software $ $
Leased Property & Equip. $ $
Mobile Property $ $
Property At Any Other Loc. $ $
Property of Others $ $
Loss of Business Income $ Period of Indemnity - (# of days)   
* RC - Replacment Cost, ACV - Actual Cash Value, SV - Stated Value
Building Information
Describe Neighborhood:
Construction Type:
Building is:
Building is:
# of Stories:
Age of Building:
Square Footage:
Roof Type:
Building Updates Made: Year Made:
Do you occupy the entire premise?
If no, please describe other occupants:
Do you have an alarm system?
Your Security System is:
Do you have? % of Building Sprinklered
Parking Lot:
Secured? If yes, in what way?
Proper Ventilation Provided?
Any forklifts on Premise: # of Forklifts:
Any Hazardous Material on Premise: If yes, explain?
Do you Store Property of Others? If yes, explain?
Your Property is Shipped by:
Describe Building Surroundings:
Right:
Left:
Rear:
Additional Coverages:
Crime Coverage:
Employee Dishonesty: Amount $ # of Employees
Money & Securities: On Premise $ Off Premise $
Earthquake:
Flood:
Cargo:
Equipment Breakdown:
Comprehensive Liability Section
Coverage Per Occurrence Aggregate Limit Deductible
Limit of Liability $ $ $
Excess Limit $ $ $
Coverage Type If Claims Made, Retro Date:
Premium Basis/Gross Revenue
  Domestic Foreign Estimated Payroll
Manufacturing $ $ $
Wholesale $ $ $
Retail $ $ $
Installation (if any) $ $ $
Provide the percentage of gross revenue based on Product Type
Percentage Product Type Percentage Product Type
% %
% %
% %
Please Answer the following questions. Yes / No Please Explain all Yes Answers
1. Is Vendors Coverage required?
2. Any Additional Insured Certificates Requirements?
3. Are any Hold Harmless Agreements required?
4. Are Waivers of Subrogation required?
5. Are any Guarantees or Warranties provided?
6. Do you have any discontinued operations?
7. Are you active in any Joint Ventures?
8. Been involved in any Mergers & Acquisitions?
9. Any operation sold or acquired?
10. Does any named insured sell to other named insureds?
11. Machinery or equimpment loaned or rented to others?
12. Any watercraft, dock floats owned, hired or leased?
13. Any parking facilities owned/rented?
14. Any recreation facilities provided on your premise?
15. Any structural alterations contemplated?
16. Do you design products for others?
17. Do you have a Side Track Agreement with a Railroad?
18. Are you an O.E.M. Supplier?
19. Do you sell Brakes, Tires, Wheels or Safety equipment?
20. Do you sell repair hoists, lifts or like equipment?
21. Do you lease employees to or from other employers?
22. Do you Sell, Treat or dispose of hazardous waste?
23. Any exposure to radioactive/nuclear materials?
24. Do you own a racing team?
25. Do you sponsor a racing team?
26. Are you a contingent sponsor of a race sanction or series?
27. Do you host any sporting or special events?
28. Which trade associations are you a member of?
Product Liability Section
1. Do you have a Quality Control program/procedures?
2. Do you maintain the following records?
    A. When and where your product(s) were manufactured?
    B. To whom your product(s) were sold and date of sale?
    C. Who supplied the parts going into the product(s)?
    D. Changes in advertising material?
3. How long are quality control and testing records kept?
4. Do products have warning labels & installation instructions?
5. Are warning labels/instructions reviewed by outside council?
6. Do you install service or demonstrate your products?
7. Are any foreign products sold, distributed or imported?
8. Is research and development conducted on new products?
9. Do you contract the manufacturing of your products to others?
10. Do you produce products for others?
11. Are products sold under label of others?
12. Do you offer training/instructions in the use of your products?
13. Do you have a written products recall procedure?
14. Have you ever or plan on recalling a product from the market?
15. Are any products related to aircraf/space industry?
16. Any products recalled, discontinued, or changed?
17. Are products of others sold/repackaged under your label?
18. Does any named insured sell to other named insureds?
19. Do you design products for others?
20. Are you a Tier 1, 2 or 3 Manufacturer?
21. Do you manufacture products other than automotive?
22. Do you sell repair hoists, lifts or like equipment?
23. Do you manufacture Brakes, Tires, Wheels or Safety Equipment?
24. Can you identify your products from those of the competitor?
25. Are your products subject to any government industry standards?
    A. If yes, are your products in full compliance?
26. Are you aware of any incident, condition, circumstance, defect or suspected defect in any product or work which may result in a claim against you that are not listed above?
27. Are you aware of any complaint or notice filed in the last three years with any governmental agency or industry regulatory body including but not limited to the U.S. Consumer Product Safety Commission concerning your products?
28. Are you aware of any study, analysis or trial conducted or being conducted by or on behalf of any government agency or industry regulatory body to examine the safety of your products?
Business Automobile Liability - Complete if auto insurance is desired
Auto Liability Limit: $ Auto Liability Deductible (if any) $
Physical Damage Comprehensive Deductible $ Collision Deductible $
Hired & Non Owned Auto Liability Desired
Hired Physical Damage Limit $
Drive Other Car Coverage Desired (If yes, please note which drivers)
Garage Keepers Liability - (Vehicles in your care, cutody or control)
Maximum Value Per Auto $ Maximum Value Per Location (GKL Limit) $
Deductible Per Auto $ Deductible Per Location $
Employee/Driver Schedule
Name Job Description Date of Birth DL # State
1.
2.
3.
4.
5.
If more than five, please attach Addendum.
Owned/Leased Vehicle Schedule
Year Make Model VIN # State Value New Garage Zip
$
$
$
$
$
For more than five auto's, please attach spreadsheet
Additional Coverages
Umbrella - Excess Liability Limit of Liability $
Employment Practices Liability Limit of Liability $
Professional Liability Limit of Liability $
Directors and Officers Liability Limit of Liability $
Internet Liability Limit of Liability $
Employee Benefits Liability Limit of Liability $
Special Events Liability Limit of Liability $
Required Underwriting Information:
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