AUTO BODY SHOP INSURANCE

First Name:
Last Name:
Business Name:
Address:
City:
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Zip Code:
Phone Number:
Fax Number:
E-Mail Address:
Who Refereed You To Our Site?
PROPERTY INFORMATION
Property Address:
Property City:
Property State:	Select... Alaska Alabama Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming
Property Zip Code:
Property County:
Total Square Footage of the Building Your Business Is In:
Square Footage Of Your Business Only:
How Many Stories:	1  2
Construction Type:	Frame  Masonry Veneer  Masonry  Superior
Roof Type:	Tile  Slate  Metal  Woodshake  Composite Material
Roof Updated:	yes no
If Yes, Year Roof was Updated:
Protection Distance:	1000 ft or less to a hydrant & 5 mi or less to a fire station  Over 1000 ft to a hydrant & 5 mi or less to a fire station  Over 5 & up to 10 mi to a fire station  Over 10 mi to a fire station
Is The Business In A Brush Area?	yes no
Is There Storage More Than 1500 Sq Ft?	yes no
Are There Smoke Detectors At This Location?	yes no
Smoke Alarm:	yes no
Theft Alarm:	None  Local  Central
Fire Alarm:	None  Local
Fire Extinguisher:	yes no
Deadbolts On All Doors?	yes no
Circuit Breakers:	yes no
Electrical Updated:	Yes, Updated  No
Heating - Air Conditioning, Thermostatically Controlled?:	yes no
Heating - Air Conditioning, Central?	yes no
Plumbing Updated:	yes no
If Yes, Year Plumbing was Updated:
Interior Automatic Fire Sprinklers:	None  Partial  Full
Is The Parking Lot Under Your Protection?	yes no
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 have you operated under your current business name:
Have you used any other business names during the past 5 years:	No Yes
Any work done on Commercial, Antique, Classic Cars:	No Yes
Number of Vehicles kept Overnight:
Where are the Vehicles stored Overnight:
How are the keys secured:
Do you loan your cars out during repairs:	No Yes
Number of pickup or vehicle deliveries per day:
Average distance one way to pickup or delivery:
Selling or consignment of vehicles:	No Yes
Average number of vehicles stored overnight:
Any LPG sales:	No Yes
Do you have a safety program in place:	No Yes
Do you test drive the repaired vehicles:	No Yes
If yes, do you check the driving records of those driving:	No Yes
Do any spray painting:	No Yes
If yes, is it in a UL approved booth:	No Yes
How many cars do you paint a week:
Average vehicle value stored overnight:
Average TOTAL value of all vehicles stored overnight:
MISC INFORMATION
Current Insurance Company:
Current Premium:
Prior coverage ever been declined:	No Yes
Ever file bankruptcy:	No Yes
Losses-Claims in the last 5 years:	none  one  two  three  four  five
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 Customers Vehicle Is Parked At Your Location:
Liability Limits Requested:	$100,000  $300,000  $500,000  $1,000,000
Questions or Comments to help the Agent:
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