Garage Liability
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Applicant Information
Applicant’s Name
*
Applicant’s Name is required.
DBA
Applicant’s Address 1
Applicant’s Address 2
City/State/Zip
Select State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Federated States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
County
Annual gross receipts for ALL operations:
Indicate the percentage of receipts generated from each of the following. Percentages must total 100%.
Contractor, Construction, or Farm Equipment Repair
%
Refrigeration Unit Repair on Refrigerated Trucks/Trailers
%
Tire Sales or Installation (if any, complete M-5977 Tire Sales Supplemental)
%
Interior Motorhome/Camper Repair incl. Appliances
%
Lift Kit Installation/Sales
What is the maximum height?
inches
%
Auto Parts Fabrication/Customization
%
Vehicle or Trailer Body Fabrication/Customization
%
Alternative Fuel Conversions
Is the applicant converting vehicles to run on hydrogen injection/fuel cells?
Yes
No
%
Towing/Wrecker, incl. Impound/Storage
%
Transporting Vehicles to/from Dealerships or Points of Sale
%
Car Wash – Self-Service
%
Car Wash/Detail incl. Automatic
%
Other Auto/Vehicle Service/Repair, not included above
%
New Auto Parts Sales, not installed
%
Used Auto Parts Sales, not installed
%
Accessory/Apparel Sales (helmets, gloves, riding gear, etc.)
%
Convenience Store Sales
%
Gasoline/Fuel Sales
If any, how many gallons sold annually?
gallons
%
LPG Sales, bulk or bottled
%
Auto Sales (vehicles licensed for road/street use)
%
Contractor, Construction, or Farm Equipment Sales
%
Off Road Vehicle or Watercraft Sales (vehicles NOT licensed for road/street use)
%
Trailer Sales
%
Other (describe)
%
Total
If Other receipts/sales, describe
Business/Physical Address(es)
Location
Location Address
Description of Business Operations
1
2
3
List all owners and employees (including independent contractors).
Location
Total No. of Owners/Employees
No. of Clerical Employees
Non-Owner Payroll
Annual Receipts
1
2
3
Additional information
Do you own the business location(s) listed above?
Yes
No
If no, does owner need to be named as an Additional Insured-Lessor of Premises (CG 20 11)?
Yes
No
For which location is Additional Insured - Lessor needed?
Name and address of Additional Insured - Lessor:
If yes, do you lease any part of the premises to others?
Yes
No
Area leased to others (in square feet)
Name of lessee:
Business operations of lessee:
Do you or any of your organization’s members own/operate any other businesses?
Yes
No
Business name and location
Description of business operations
Relationship with this business
Any shared employees?
Yes
No
Does this business carry separate liability insurance?
Yes
No
Is this a new venture?
Yes
No
What date did you begin operating/owning this business
Coverage Information
Each Occurrence / General Aggregate / Products-Completed Operations Aggregate
$50,000 / $100,000 / $100,000
$500,000 / $1,000,000 / $1,000,000
$100,000 / $200,000 / $200,000
$750,000 / $1,500,000 / $1,500,000
$300,000 / $600,000 / $600,000
$1,000,000 / $2,000,000 / $2,000,000
Provides coverage for customers’ vehicles on a Direct Primary basis
Blanket Additional Insured Endorsement
Location
Average Vehicle Value
Max. Vehicle Value
Avg. No. of Vehicles on Lot
Max. No. of Vehicles on Lot
Location Limit
1
2
3
Garagekeepers Deductible
$500
$1000
$2500
$5000
ADDITIONAL INSUREDS
Name
Address 1
Address 2
City/State/Zip
Select One
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Federated States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Insurable Interest/Relation
Include Limited Waiver (Blanket Waiver not available)
Name
Address 1
Address 2
City/State/Zip
Select One
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Federated States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Insurable Interest/Relation
Include Limited Waiver (Blanket Waiver not available)
List prior insurance coverage information and provide loss runs.
Insurance Company
Policy Term
Premium
Any Losses?
Total Amount Paid
Yes
No
Yes
No
Yes
No
If any prior losses, provide loss details
Has your coverage ever been cancelled or nonrenewed?
Yes
No
If yes, explain
Underwriting Information
Provide a breakdown of the types of vehicles repaired, serviced, stored, or towed. Must total 100%.
Vehicle Types
Boats, Jet Skis, or Watercraft
Buses (any motor vehicle designed to transport 16 or more passengers)
Commercial Trucks, Truck Tractors, or Trailers
Contractor, Construction, or Farm Equipment
Motorcycles, Mopeds, or Scooters
Motorhomes or Campers
Off Road Vehicles (ATV, golf cart, side-by-side, snowmobile, UTV)
Private Passenger Vehicles (pick-up, sedan, SUV, van)
Other (describe)
Total
% of Total Operations
%
%
%
%
%
%
%
%
%
Provide a breakdown of the work you do. Must total 100%.
Type of Work Provided
Autobody Repair/Painting (incl. dent repair, fiberglass, glass/windshield, painting, powder coating)
Car Wash/Detail, including Automatic (incl. clear coat, wax)
Car Wash – Self-Service
Cosmetic Repair (incl. alarm/sound system, bedliner, navigation, upholstery, window tint, wrap)
Oil & Lube/Tune Up (incl. battery, brakes, belts, fluids, hoses, oil change, inspection station, tire alignment/repair/rotation)
Tire Sales (if any, complete M-5977 Tire Sales Supplemental)
Towing/Wrecker, including impound/storage
Vehicle Service/Repair, not included above (incl. A/C and heat, drive shaft, electrical, engine, hitch/fifth wheel, hydraulics, muffler, power train, radiator, suspension/frame, tire repair, transmission, wheel/rim repair)
Other (describe)
Total
% of Total Operations
%
%
%
%
%
%
%
%
%
Do you do any of the following? Check all that apply
Accessory/Apparel Sales
Interior Motorhome/Camper Repair, including Appliances
Auto Parts Sales
Lift Kit Installation/Sales (body or suspension lifts)
Alternative Fuel Conversions
LPG Sales (bulk or bottled)
Convenience Store Sales
Parts Fabrication/Customization
Gasoline/Fuel Sales
Vehicle/Trailer Body Fabrication/Customization
Where do your operations take place? Must total 100%
Your Shop
%
Customer’s Location
%
Roadside
%
Do you pick up or deliver any customer’s auto
Yes
No
If yes, explain
COMMERCIAL TRUCK, TRUCK TRACTOR, OR TRAILER & HEAVY EQUIPMENT
Do you sell, install, or repair any tanks used to transport chemicals, petroleum products, or other bulk liquids?
Yes
No
If yes, explain
What percentage of your operation involves this work?
%
Do you service any refrigeration unit on refrigerated trucks or trailers?
Yes
No
If yes, what percentage of your operation involves this work?
%
Do you sell, install, service, or repair pumps or hoses used in firefighting or fire suppression?
Yes
No
Do you operate or have common ownership in a trucking or transportation business?
Yes
No
Provide the business name of these operations
Do you perform any service, repair, or maintenance on vehicles owned or operated by this business?
Yes
No
What percentage of your operation involves this work?
%
Do you perform any work in oil fields, on petroleum pipelines, for mining operations, or for, or on behalf of, any oil, gas, energy, or petroleum-related entity?
Yes
No
If yes, describe:
What percentage of your operation involves this work?
%
For which entity(ies) is this work performed?
Does this entity(ies) need to be listed as Additional Insured?
Yes
No
Is any work done over-the-hole or on oil rigs?
Yes
No
Do you service any crane, cherry picker, or boom lift?
Yes
No
If yes, describe:
What percentage of your operation involves this work?
%
TOWING
What percentage of your operation involves repossession?
%
Do you transport vehicles to/from dealerships or points of sale?
Yes
No
If yes, do you drive (not tow/haul) these vehicles (i.e. driveaway)?
Yes
No
Do you hire subcontractors, independent contractors, or any other non-employees to tow/haul vehicles on your behalf
Yes
No
If yes, describe
Annual costs to hire such drivers
OFF ROAD VEHICLES
Do you sell, service, or repair any dirt bike, motocross bike, or similar?
Yes
No
If yes, describe:
Do you rent any ATV, golf cart, snowmobile, UTV, watercraft, or any other vehicle not licensed for road/street use?
Yes
No
If yes, describe
How many units are available for rent?
Annual gross receipts for rental operations
ADDITIONAL INFORMATION
Do you sell any vehicles?
Yes
No
If yes, what type(s) of vehicles do you sell?
Do you sell any vehicle with a salvage, rebuilt, or junk title, or dismantle such vehicles for purpose of resale of parts?
Yes
No
Do you enhance any engine for high performance, including supercharging, turbocharging, horsepower augmentation, or other such enhancements?
Yes
No
If yes, describe
Do you sell, service, repair, maintain, up-fit, customize, operate, or sponsor any vehicle used in racing, competitive motorsports, rock crawling, mud bogging, or similar activities?
Yes
No
Do you assemble, reconstruct, restore, or custom manufacture any motorcycle, land motor vehicle not designed for travel on public roads, or antique, classic, or vintage auto?
Yes
No
Do you sell, install, or repair any breath alcohol ignition interlock device (BAIID) or similar device?
Yes
No
Do you convert, customize, or fabricate any vehicle for a purpose other than intended by the manufacturer?
Yes
No
If yes, describe
Do you convert any vehicle to contain living/sleeping quarters?
Yes
No
Do you sell the converted vehicle(s)
Yes
No
If yes, to whom
Missing Required Information
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