1
Auto Service Application
Policy # 
 AGENCY ID:
 AGENCY:
 PRODUCER ID:
 AGENT:
Status: 
 Date Created:
 Named Insured:
 Policy Period:
 DBA: 
                  to
Partnership Corporation Individual LLC Other
 Mailing Address Street  City  State  Zip 
 Contact: First Last Title
 Phone: -  ext. 
 1Number of years this applicant has been in business:
 2Any losses, PAID or NOT, in the previous 3 years? No Yes
 3Any lapses in coverage in the previous 3 yrs? No Yes
 4Has coverage been cancelled, declined or non-renewed in the past 3 years? No Yes
PRIOR CARRIER AND LOSS INFORMATION (losses paid or not) - PAST 3 YEARS
Carrier
Policy Number
Policy Period
Premium
to
to
to
Date(s) of Loss
Description or Type of Claim
O/C
Paid
Reserve
REMARKS
Location of
2
 DBA: 
Lessor's Risk Only
 Address: 
 City:   State:   Zip: 
 How Long here? 
NO CLASS CURRENTLY SELECTED (ON LOC FORM)
GARAGE COVERAGES
 EMPLOYEES (Do not count clerical)
Full Time
Part Time
 Active Owners: 
 Mechanics: 
 Technicians: 
 Body/Paint Workers:
 Car Wash Detailers: 
 Cashiers: 
 Others: 
 Payroll: 
 Loss or Dmg. to Cust. Autos
 Loss or Dmg. to Cust. Autos and Other Cust. Prop.
 N/A
LEGAL LIABILITY DIRECT PRIMARY
 Limit $ 
Ded. $
Includes Comprehensive/Collision
 
 GENERAL LIABILITY  $ 
Aggregate: 
 Property Damage Deductible:
CHECK TO INCLUDE:
ASR Property Extension 
Liquor Liability (see section below)
Hired Auto 
Non Owned Auto
Per Year
Per Employee - # 
Fire Legal($100,000 Incl.) 
Additional Insureds - Total #: 
 Stop Gap
Limit -    Per Policy
 
 Actual Payroll:   For All Locations
 Employee Benefits -
Emp. Count:
Limit:
 Premises Med Pay Included ($5,000)
 Personal Injury and Advertising Injury Incl (same as GL Limit)
 see section below to add additional GL class codes
PROPERTY (Building and Personal Property Co-Insurance is 90%. Valuation is replacement Cost) - CRIME - INLAND MARINE
See attached Additional Buildings subform. Total # -
 
Limit
Deductible
 Building 1 -
 Open Sides
 
 $ 
 
Pumps 
 $ 
Canopy 
 $ 
 
 L.D.L.P.
 $ 
# 
 
Limit
Deductible
 Personal Property - Open Sides 
 $ 
 
Hoses/Nozzles 
 $ 
Gas In Ground 
 $ 
 
 1/4 Indemnity 
 Actual Loss Sustained 
 N/A 
 Business Income - w/ Extra Exp.
 $ 
None
 Ordinance or Law Coverage Total Limit $ 
(Combined Limit for Coverage B&C)
Ded 
Coverage A Included 
Open 24x7 - 
No Yes
 Monitored Central Station Alarm?
No
Yes
Accept/Reject Terrorism Coverages
*See Attached
Coverage Forms
 Building(s), Gas Pumps and/or Canopy 
Special W/O Theft 
 Personal Property, Hoses & Nozzles and/or Gas In Ground: 
Special W/O Theft 
 Business Income - w/Extra Exp.
Construction Code: 
Special W/O Theft 
3
1
  Any repair of trucks/tractors? No Yes
2
  Any trailer hitch service or installation? No Yes
3
 Any R.V. service other than mechanical?
No Yes
4
  Any servicing of propane systems? No Yes
5
  Any retail sales of used parts? No Yes
6
  Any auto salvage or dismantling work? No Yes
7
  Any work on hydraulic systems? No Yes
8
  Any tire recap or retread? No Yes
9
  Any mobile repair operations? No Yes
10
  Is Auto spray painting performed? No Yes
   If yes , is a U.L. approved booth used? No Yes
11
  Is welding performed? No Yes
   If yes , are auto gas tanks welded? No Yes
12
  # of service pits (must have safety nets)
13
  Condition of Equipment?
14
  Age of car wash equipment?
15
  Are Mechanics/Techs Certified? No Yes N/A
16
  Are any service bays leased to others? No Yes
17
 Is applicant involved in other business?
No Yes
18
 Does applicant occupy entire premises?
No Yes
19
  Building construction?
20
  Building square footage?
21
  Year Built?
22
  Bldg updated in the past ten years?
No Yes
23
  Is building sprinklered? No Yes
24
  How far to a fire station?
  miles
25
  How far to a fire hydrant?
  feet
26
  Is pump shutoff accessible? No Yes
27
  Fire extinguishers tagged and current? No Yes
28
  Is the entire lot well lit at night? No Yes
29
  Security Cameras? No Yes
30
  Security Guard/Nightwatchman? No Yes
31
 Are firearms ever kept on the premises?
No Yes
   If yes, where are they stored?
32
 Are animals ever kept on the premises?
No Yes
33
  Is there cooking on premises? No Yes
   If yes, deep fat frying? No Yes
34
  Is there an ansul system? No Yes
35
  Is applicant the owner of building(s)? No Yes
36
  Any check cashing service? No Yes
37
 If propane sales, which type? Exchange Only Fill* N/A
Propane Reciepts $ 
 
38
 Any automated cash payment machines (Quick Pay)? No Yes
39
 Are "Employee's Only" signs posted in work areas? No Yes N/A
40
 Are checklists used for work performed? No Yes N/A
41
 Is a Sweep Schedule used? No Yes
42
 Housekeeping?
43
 Is there an ATM? No Yes  If yes, is it located inside or outside? Inside Outside
44
 Are customer autos test driven? N/A No Yes
If Yes- (a.) By whom?: 
 
(b.) Regular test drive route?
No Yes
45
 Where are customer autos stored after hours?
Inside Bldg Inside Fenced/Secured lot Unprotected Lot No Storage
46
 Are keys removed from customer autos when work is not being performed?  N/A No Yes
47
 Where are keys to customer autos stored? During business hours: 
  After business hours: 
 
48
  Do employees use their own autos for company business? No Yes - How often: 
49
 Are customers picked up and/or delivered? N/A No Yes - Radius traveled: miles
50
 Are customer autos picked up and/or delivered? N/A No Yes - Radius traveled: miles
4
51
  a. Does applicant own or operate a tow truck? No Yes - # 
   b. Are TOW TRUCKS used EXCLUSIVELY to haul vehicles the insured will perform repair work on? No Yes
   c. Does the applicant do any CONTRACT TOWING (AAA, Police, etc.)? No Yes
52
  Any ownership/sponsorship/repair of racing vehicles? No Yes  If yes explain: 
53
  Are autos modified outside manufacturers specifications? No Yes If yes explain: 
54
  What work is regularly subcontracted to others? 
55
 Is waste material (oil, etc) picked up by a regular service? N/A No Yes
If Yes, frequency?: 
CRIME (MONEY & SECURITIES/EMPLOYEE DISHONESTY)
56
  Is currency placed in safe after hrs?  No Yes
   If no, where? 
57
  Are bank deposits made daily, M-F?  No Yes
58
  Who makes bank deposits? 
LIQUOR LIABILITY
59
 Beer/Wine Reciepts $
Hard Liquor Reciepts $
60
  Name on liquor license: 
61
  Liquor license(s) ever suspended or revoked?  No Yes Provide Details: 
62
  Have there been any liquor liability claims?  No Yes Provide Details: 
63
  Are signs posted in clear view at each location prohibiting sales to minors?  No Yes
64
  Are signs posted in clear view at each location prohibiting "On premise" consumption of alcohol?  No Yes
65
  Is liquor secured after legal selling hours?  No Yes How: 
66
  Are there liquor sales other than beer and wine?  No Yes
BUSINESS AUTOS ( Liability Limit will be the same as GENERAL LIABILITY Limit)
*See Attached
Number of Business Autos: 
OTHER GENERAL LIABILITY CLASSES (Includes premises/operations)
      61212 Lessors Risk # Lessors Risks
* See Attached Subform
    Misc. GL
 Type of Operation: 
 Premium Basis (Sales): 
 Premium (Refer to SII): 
 Additional Information: 
 
    49451 Vacant Land
 Total # acres:
 Location Address:
 
5
MORTGAGEES - LOSS PAYEES - CERT. HOLDERS THAT ARE NOT ADDITIONAL INSUREDS
- *See Attached
List ALL ACTIVE OWNERS, MECHANICS, TECHNICIANS (i.e., lube/oil, smog, etc.), BODY/PAINT MEN, and any OTHERS who WORK
ON CUSTOMER CARS OR DRIVE in their job, MVR's are required for each individual listed below.
Name Position DOB D.L.# & State FT/PT Yrs Exp
FT PT
FT PT
FT PT
FT PT
FT PT
FT PT
FT PT
FT PT
FT PT
FT PT
Remarks:

 
6
Additional Insured

Interest: 
 
Details: 
Name:
Address:
Address:
City:
State:
Zip:

Interest: 
 
Details: 
Name:
Address:
Address:
City:
State:
Zip:

Interest: 
 
Details: 
Name:
Address:
Address:
City:
State:
Zip:

Interest: 
 
Details: 
Name:
Address:
Address:
City:
State:
Zip:
7
Additional Building's and/or Personal Property
 
Limit
Deductible
 Building -
 Open Sides
 
 $ 
 
Pumps 
 $ 
Canopy 
 $ 
 
 
Limit
Deductible
 Personal Property -
Open Sides 
 $ 
 
Hoses/Nozzles 
 $ 
Gas In Ground 
 $ 
 
 L.D.L.P.
 $ 
# 
 Ordinance or Law Cov Total Limit $ 
(Combined Limit for Cov B&C)
Ded 
Coverage A Included 
 Coverage Form for...
 Building(s), Gas Pumps and/or Canopy 
Special Form  W/O Theft
 Personal Property, Hoses & Nozzles and/or Gas In Ground: 
Special Form  W/O Theft
 Building construction? (codes 1 - 3)
 Building square footage?
 Year Built?
 Bldg updated in the past ten years?
No Yes
 Is building sprinklered?
No Yes
 Monitored Central Station Alarm?
No Yes
Details of operations for this building:
 
Limit
Deductible
 Building -
 Open Sides
 
 $ 
 
Pumps 
 $ 
Canopy 
 $ 
 
 
Limit
Deductible
 Personal Property -
Open Sides 
 $ 
 
Hoses/Nozzles 
 $ 
Gas In Ground 
 $ 
 
 L.D.L.P.
 $ 
# 
 Ordinance or Law Cov Total Limit $ 
(Combined Limit for Cov B&C)
Ded 
Coverage A Included 
 Coverage Form for...
 Building(s), Gas Pumps and/or Canopy 
Special Form  W/O Theft
 Personal Property, Hoses & Nozzles and/or Gas In Ground: 
Special Form  W/O Theft
 Building construction? (codes 1 - 3)
 Building square footage?
 Year Built?
 Bldg updated in the past ten years?
No Yes
 Is building sprinklered?
No Yes
 Monitored Central Station Alarm?
No Yes
Details of operations for this building:
8
Loss or Damage to Lessors Property Details

Building Number:
Description of Premises:
Description of 'Leased Property':
Name of Lessor:

Building Number:
Description of Premises:
Description of 'Leased Property':
Name of Lessor:

Building Number:
Description of Premises:
Description of 'Leased Property':
Name of Lessor:

Building Number:
Description of Premises:
Description of 'Leased Property':
Name of Lessor:

Building Number:
Description of Premises:
Description of 'Leased Property':
Name of Lessor:

Building Number:
Description of Premises:
Description of 'Leased Property':
Name of Lessor:

Building Number:
Description of Premises:
Description of 'Leased Property':
Name of Lessor:
9
Specified Vehicles


 
Year: 
Make: 
Model: 
VIN: 
Use: 
Personal Use
Business Use
Value $ 
Tow Truck: 
Radius: 
Comp&Coll Ded $ 
 
 
Year: 
Make: 
Model: 
VIN: 
Use: 
Personal Use
Business Use
Value $ 
Tow Truck: 
Radius: 
Comp&Coll Ded $ 
 


 
Year: 
Make: 
Model: 
VIN: 
Use: 
Personal Use
Business Use
Value $ 
Tow Truck: 
Radius: 
Comp&Coll Ded $ 
 
 
Year: 
Make: 
Model: 
VIN: 
Use: 
Personal Use
Business Use
Value $ 
Tow Truck: 
Radius: 
Comp&Coll Ded $ 
 


 
Year: 
Make: 
Model: 
VIN: 
Use: 
Personal Use
Business Use
Value $ 
Tow Truck: 
Radius: 
Comp&Coll Ded $ 
 
 
Year: 
Make: 
Model: 
VIN: 
Use: 
Personal Use
Business Use
Value $ 
Tow Truck: 
Radius: 
Comp&Coll Ded $ 
 
10
Lessors Risk

Tenants Name:
Type of Operation:
Total Sq. Ft:
Loc. Address:
City:
State:
Zip:

Tenants Name:
Type of Operation:
Total Sq. Ft:
Loc. Address:
City:
State:
Zip:

Tenants Name:
Type of Operation:
Total Sq. Ft:
Loc. Address:
City:
State:
Zip:

Tenants Name:
Type of Operation:
Total Sq. Ft:
Loc. Address:
City:
State:
Zip:

Tenants Name:
Type of Operation:
Total Sq. Ft:
Loc. Address:
City:
State:
Zip:
11
Mortgagees - Loss Payees - Cert. Holders

Type:
Mortgagee
Cert. Holder
Loss Payee
Name:
Address:
Address:
City:
State: 
Zip: 

Type:
Mortgagee
Cert. Holder
Loss Payee
Name:
Address:
Address:
City:
State: 
Zip: 

Type:
Mortgagee
Cert. Holder
Loss Payee
Name:
Address:
Address:
City:
State: 
Zip: 

Type:
Mortgagee
Cert. Holder
Loss Payee
Name:
Address:
Address:
City:
State: 
Zip: 

Type:
Mortgagee
Cert. Holder
Loss Payee
Name:
Address:
Address:
City:
State: 
Zip: 
12

Property Plus Extension - Exclusions
Accounts Receivable
 
Above & Below GND fuel storage tanks/fuel pumps
Business Income/Extra Expense
Debris Removal
Electronic Data Proc.
Employee Dishonesty
Employee Tools
Fire Department Service Charge
Forgery/Alteration
Loss Data Preparation
Money & Securities
Newly Acquired LOCS - BLDGS & BUS Personal Property
Ordinance or Law
 
Outdoor Properties
Personal Effects & Property of Others
Pollutant Cleanup
Property in Transit
Property off Premises
Refrigerated Goods Spoilage
Signs: ATT/unattached, indoor/outdoor
Utility Services, Business Income
Utilities Services, Direct Damage
Valuable Papers
 
 
Optional Terrorism Coverage's
Coverage Part(s)
Coverage Selection
Commercial Property (optional)
Accept
Reject
Commercial General Liability
Accept
Reject
Commercial Garage
Accept
Reject
Inland Marine
Accept
Reject