Name
*
First Name
Last Name
Business Name
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Nature of Business/Operations
*
Contact Name
*
Title
Phone
*
(###)
###
####
Email
*
Number of Years in Business
FEIN #
Have there been any losses in the past 5 years?
Proposed Effective Date:
Total Number of Employees
Name
First Name
Last Name
Job Title
If Driver
Date of Birth
MM
DD
YYYY
Driver License # and State
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Construction (check all that apply)
Building Square Footage
Year Built
Number of Stories
Are you the Building Owner?
Are you a Tenant?
Are there other tenants in your building?
If YES, describe operations, protection
Need Tenants, Betterments, Improvement Coverage?
Are there any Additional Insureds?
If YES, please provide address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Any History of Flooding/Water Back-Up?
If YES, explain
Feet to Fire Hydrant
Miles to Fire Station
Central Station Fire Alarm?
Central Station Burglar Alarm?
Is the Building Sprinklered?
Deductible:
Are you interested in a quote for any of the following?
How did you hear about us?
Desired Deductible:
Type:
Describe extent of repair services on premises:
Percentage of operations that is servicing or restoring collector vehicles:
# Vehicles serviced per month?
Describe customer key storage:
Are customer vehicles picked up and/or delivered?
If YES, do you use a third party source?
Number of Repair Plates:
Number of Transporter Plates:
Year:
Make:
Model:
VIN:
Use:
Where are customer vehicles stored overnight?
Average number of vehicles stored overnight:
Any ownership/sponsorship/repair of racing vehicles?
Any service of owned vehicles?
Any service of non-owned vehicles?
Any service bays leased to others?
Is welding performed?
If YES, are vehicle gas tanks welded?
Is any vehicle spray painting performed?
Restoration %
Painting %
Parts Fabrication %
Auto Sales %
Non-Collector Auto Sales %
Non-Collector Body Work %
Auto Storage %
Memorabilia Sales %
Auction %
Does booth have a fire suppression system?
Is booth constructed of steel, aluminum, concrete or masonry material?
Are the interior surface of the booth smooth and continuous?
Are the floors of the booth made of a non-combustible material?
Is all electrical wiring explosion-proof?
Does booth have mechanical ventilation with an independent exhaust system venting to the exterior of the building?
Are there visible gauges or alarms that ensure air required velocity is maintained?
If NO to any of the above, please explain:
Are there any open flames or spark producing equipment within 20 feet of booth?
If YES, please explain:
