Program Application

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

General Information
Property
Comprehensive Liability
Product Liability
Business Automobile Liability

GENERAL INFORMATION
Legal Name:
Corporation/LLC Partnership Individual Joint Venture Subsidiary Other
Do you operate under a d.b.a?	Yes No
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?	Yes No
Applicant operates as:	Manufacturer Wholesaler Distributor Retailer Installer Service Provider
Coverage Currently In Force?	Yes No
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	$	RC ACV SV	$
Leashold Improvements	$	RC ACV SV	$
Business Personal Property	$	RC ACV SV	$
Raw Materials	$	RC ACV SV	$
Work in Progress (WIP)	$	RC ACV SV	$
Stock & Inventory	$	RC ACV SV	$
Computer Hardware	$	RC ACV SV	$
Computer Software	$	RC ACV SV	$
Leased Property & Equip.	$	RC ACV SV	$
Mobile Property	$	RC ACV SV	$
Property At Any Other Loc.	$	RC ACV SV	$
Property of Others	$	RC ACV SV	$
Loss of Business Income	$	Period of Indemnity - (# of days)
* RC - Replacment Cost, ACV - Actual Cash Value, SV - Stated Value
Building Information
Describe Neighborhood:	Residential Commercial Industrial
Construction Type:	Wood Frame Masonry-Wood Roof & Floors Masonry-Concrete & Steel Roof/Floors Fire Resistive
Building is:	Inside City Limits Outside City Limits
Building is:	Owned Rented
# of Stories:
Age of Building:
Square Footage:
Roof Type:
Building Updates Made:	Wiring Plumbing Roofing Heating & Air		Year Made:
Do you occupy the entire premise?	Yes No
If no, please describe other occupants:
Do you have an alarm system?	Yes No	Smoke Fire Burglar Other
Your Security System is:	Central Station Policy Gong Alarm Video Surveillance
Do you have?	Fire Extinguishers Sprinkler System	% of Building Sprinklered
Parking Lot:	Yes No
Secured?	Yes No	If yes, in what way?
Proper Ventilation Provided?	Yes No
Any forklifts on Premise:	Yes No	# of Forklifts:
Any Hazardous Material on Premise:	Yes No	If yes, explain?
Do you Store Property of Others?	Yes No	If yes, explain?
Your Property is Shipped by:	Company Vehicles Standard Carrier (i.e., UPS / FedEx) Common Carrier
Describe Building Surroundings:
Right:
Left:
Rear:
Additional Coverages:
Crime Coverage:	Yes No
Employee Dishonesty:	Yes No	Amount $	# of Employees
Money & Securities:	Yes No	On Premise $	Off Premise $
Earthquake:	Yes No
Flood:	Yes No
Cargo:	Yes No
Equipment Breakdown:	Yes No

Comprehensive Liability Section
Coverage	Per Occurrence	Aggregate Limit	Deductible
Limit of Liability	$	$	$
Excess Limit	$	$	$
Coverage Type	Occurrence Claims Made		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?	Yes No
2. Any Additional Insured Certificates Requirements?	Yes No
3. Are any Hold Harmless Agreements required?	Yes No
4. Are Waivers of Subrogation required?	Yes No
5. Are any Guarantees or Warranties provided?	Yes No
6. Do you have any discontinued operations?	Yes No
7. Are you active in any Joint Ventures?	Yes No
8. Been involved in any Mergers & Acquisitions?	Yes No
9. Any operation sold or acquired?	Yes No
10. Does any named insured sell to other named insureds?	Yes No
11. Machinery or equimpment loaned or rented to others?	Yes No
12. Any watercraft, dock floats owned, hired or leased?	Yes No
13. Any parking facilities owned/rented?	Yes No
14. Any recreation facilities provided on your premise?	Yes No
15. Any structural alterations contemplated?	Yes No
16. Do you design products for others?	Yes No
17. Do you have a Side Track Agreement with a Railroad?	Yes No
18. Are you an O.E.M. Supplier?	Yes No
19. Do you sell Brakes, Tires, Wheels or Safety equipment?	Yes No
20. Do you sell repair hoists, lifts or like equipment?	Yes No
21. Do you lease employees to or from other employers?	Yes No
22. Do you Sell, Treat or dispose of hazardous waste?	Yes No
23. Any exposure to radioactive/nuclear materials?	Yes No
24. Do you own a racing team?	Yes No
25. Do you sponsor a racing team?	Yes No
26. Are you a contingent sponsor of a race sanction or series?	Yes No
27. Do you host any sporting or special events?	Yes No
28. Which trade associations are you a member of?	Yes No

Product Liability Section
1. Do you have a Quality Control program/procedures?	Yes No
2. Do you maintain the following records?
A. When and where your product(s) were manufactured?	Yes No
B. To whom your product(s) were sold and date of sale?	Yes No
C. Who supplied the parts going into the product(s)?	Yes No
D. Changes in advertising material?	Yes No
3. How long are quality control and testing records kept?	Yes No
4. Do products have warning labels & installation instructions?	Yes No
5. Are warning labels/instructions reviewed by outside council?	Yes No
6. Do you install service or demonstrate your products?	Yes No
7. Are any foreign products sold, distributed or imported?	Yes No
8. Is research and development conducted on new products?	Yes No
9. Do you contract the manufacturing of your products to others?	Yes No
10. Do you produce products for others?	Yes No
11. Are products sold under label of others?	Yes No
12. Do you offer training/instructions in the use of your products?	Yes No
13. Do you have a written products recall procedure?	Yes No
14. Have you ever or plan on recalling a product from the market?	Yes No
15. Are any products related to aircraf/space industry?	Yes No
16. Any products recalled, discontinued, or changed?	Yes No
17. Are products of others sold/repackaged under your label?	Yes No
18. Does any named insured sell to other named insureds?	Yes No
19. Do you design products for others?	Yes No
20. Are you a Tier 1, 2 or 3 Manufacturer?	Yes No
21. Do you manufacture products other than automotive?	Yes No
22. Do you sell repair hoists, lifts or like equipment?	Yes No
23. Do you manufacture Brakes, Tires, Wheels or Safety Equipment?	Yes No
24. Can you identify your products from those of the competitor?	Yes No
25. Are your products subject to any government industry standards?	Yes No
A. If yes, are your products in full compliance?	Yes No
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?	Yes No
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?	Yes No
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?	Yes No

Business Automobile Liability - Complete if auto insurance is desired
Auto Liability Limit:	$	Auto Liability Deductible (if any)	$
Physical Damage	Yes No	Comprehensive Deductible	$	Collision Deductible	$
Hired & Non Owned Auto Liability Desired	Yes No
Hired Physical Damage	Yes No	Limit	$
Drive Other Car Coverage Desired	Yes No (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	Yes No	Limit of Liability	$
Employment Practices Liability	Yes No	Limit of Liability	$
Professional Liability	Yes No	Limit of Liability	$
Directors and Officers Liability	Yes No	Limit of Liability	$
Internet Liability	Yes No	Limit of Liability	$
Employee Benefits Liability	Yes No	Limit of Liability	$
Special Events Liability	Yes No	Limit of Liability	$
Required Underwriting Information:
Signed Application
Auto & Driver Schedule
5 Years of Hard Copy Loss Reports

The professional expertise from Mr. Bob Corwin and his team members provided valuable advices that helped us saved money, made correct decisions and suggested solutions when problems occurred. Alliant and SEIA is the answer to the business insurance because they are reliable and we trust them.

Mei Lien Chang, Vice President, Trade Union International, Inc.

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