Date Insurance Needed
*
Name of Business
*
Types of Entity
*
Location Address
*
City
*
State
*
Zip
*
Mailing address if different
Main Telephone
*
Main Mobile
*
Fax Number
Contact Person
*
Contact Person Phone Number
Contact Person Email
*
New Venture
Yes
No
Current Carrier
Current Carrier Expiration Date
# of years in Business
# of losses in last 3 years
# of dealer plates
Employee Information
Owners # of F/T
Owners # of P/T
Owners - How many have furnished autos?
Mechanics # of F/T
Sales # of F/T
Clerical # of F/T
Sales # of P/T
Sales - How many have furnished autos?
Clerical - How many have furnished autos?
Mechanics # of P/T
Mechanics - How many have furnished autos?
Non-Employees # of P/T
Clerical # of P/T
Non-Employees - How many have furnished autos?
Porters # of F/T
Porters # of P/T
Porters - How many have furnished autos?
Non-Employees # of F/T
Desired Coverages
Liability
Select
$100,000
$300,000
$500,000
$1,000,000
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Repair work on customers cars
Yes
No
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Dealers Open Lot (Value of Inventory)
Comments/Additional Coverage Requested
Lot Protection
Fenced
Inside
No Protection
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Max Value of Any Unit
Average # of Cars
Average Value Per Unit
Building Value
Highest Value of customers vehicles kept on premise at one time
Coverage for:
Contract Drivers
Unaccompanied Test Drives
False Pretense
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Property
Contents
Person providing information
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