Garage Keepers Quote Request
 

Please note that this form is for a REQUEST ONLY. By submitting this form it does not bind coverage in any way.  If you do not hear from us in a reasonable amount of time, ASSUME WE DID NOT GET THIS REQUEST FOR AN INSURANCE QUOTE, and call our office.

I understand that filling out and submitting this form DOES NOT bind coverage in any way, and the only way coverage can be bound will be when I am informed of a binder or policy is issued by the agent representing me.
General Information
Name of Business:
Contact:
E-mail Address:
Business Address:
City:
State:
Zip:
Business Phone:  
Fax:
Years in Business

Property Information
Property Address:
Property City:         
State:
ZIP:
Property County:  
Total Square Footage of the Building Your Business is in:
Square Footage of your Business Only:
How many stories is this building?
Construction Type:
Roof Type:
Has the roof been Updated:
If yes, Year Roof was Updated:
Protection Distance:
Is the business in a brush area?
Is there storage more than 1500 sq. ft?
Are there smoke detectors at this location?
Theft Alarm?
Fire Alarm?
Fire Extinguisher?
Deadbolts on all Doors?
Circuit Breakers?
Electrical updated?
Heating - Air Conditioning, Thermostatically Controlled?
Heating - Air Conditioning, Central?
Plumbing Updated?
If yes, year plumbing was updated:
Interior Automatic Fire Sprinklers:
Is the parking lot under construction?

Underwriting information
Please describe the nature of your business:
Number of Owners:  
Number of Employees:  
Number of Employees that work on vehicle:  
Payroll of Owners:  
Payroll of Employees:  
Total annual gross receipts:  
Total annual sub costs:  
Business license number:  
Bureau auto repair number (if different):  
License Type:  
Years of Experience:  
How many years operated under current business name?  
Have you used any other business names during the past 5 years?  Yes No  
Work done on Commercial, Antique, Classic Cars?  Yes No
Number of vehicles kept overnight::  
Where are the vehicles stored overnight?
How are the keys secured?
Do you loan cars out during repairs?  Yes No
Number of pickup or vehicle deliveries per day:  
Average distance one way to pickup or delivery:  
Selling or consignment of vehicles?  Yes No
Average number of vehicle stored overnight?:  
Any LPG sales?  Yes No
Do you have a safety program in place?  Yes No
Do you test drive the repaired vehicles?  Yes No
If yes, do you check the driving record of those driving?  Yes No
Do you spray paint vehicles?  Yes No
If yes, is it in a UL approved booth?  Yes No
How many cars do you paint a week?  
Average vehicle value stored overnight?  
Average TOTAL value of all vehicles stored overnight?  

Loss History Information
Current Insurance Company:
Current Premium:
Prior Coverage ever been declined?
Ever file bankruptcy?  
Loss claims in the last 5 years:  
If yes, date, amount paid and description of each loss claim:

Coverage Information
Building Limit Requested:
Office Contents Limit Requested:
Shop Contents Limit Requested:
Loss of Rents Limit Requested:  
Auto liability limit requested while test driving:  
Maximum per vehicle damage (collision) loss limit while test driving:  
Maximum per vehicle damage (comp) loss limit while the customer's vehicle is parked at your location:  
Liability limits requested:
Any additional comments: